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With  Observations  on  the  present  State  and  Prospects  of  Egypt  and  Palestine, 
and  on  tha  Climate^  Natural  History,  and  Antiquities  of 

the  Coontries  visited. 

Second  Edition,  enlarged,  with  Maps  and  other  Illustrations.    8vo. 



With  Notes  on  the  State  of  Science,  and  a  Guide  to  the  Hospitals  and  Sanitory 

Establishments  of  Vienna.     Crown  8vo. 


With  Bemarks  on  Stella,  and  on  lome  of  his  Writings  hitherto  unnoticed. 

Second  Edition,  enlarged,  with  Portrait  of  Stella,  and  other 

Illustrations.     8vo. 


lllustrattb  ^iBioruallg  nxib  iropogrupljunlln. 

Second  Edition,  enlarged,  with  a  Map,  an  Itinerary,  Plan  of  the  Battle  of  the  Boync, 
and  Eighty-four  Illustrations  engraved  on  Woud.     Cruwn  8vo. 


Crown  8vo. 




Which  has  provailed  in  the  Irish  Workhouses. 


In  the  rrets. 













wwLLcm  or  the  botal  ooujeob  op  bdroiohs  nr  ibkulMDi  sdbobom  to  n.  mark'm  ophthalmic  hohpitali 


KtV»  BTC. 




/<^^..  a..  ///. 


BT  M.  H.  OIUo 





THIS  WORK  18, 






In  the  Introductory  Chapter  I  have  entered  so  fully  into 
the  circumstances  attending  the  publication  of  this  work, 
that  but  few  prefatory  observations  are  necessary.  I 
have  laboured,  and  I  trust  not  in  vain,  to  expose  error 
and  establish  truth ;  to  lay  down  just  principles  for  an 
accurate  diagnosis  of  Diseases  of  the  Ear ;  to  rescue  their 
treatment  from  empiricism,  and  found  it  upon  the  well- 
established  laws  of  modem  pathology,  practical  surgery, 
and  reasonable  therapeutics.  In  dealing  with  my  sub- 
ject it  was  necessary  to  review  the  practice  and  opinions 
of  others :  yet,  though  on  certain  points  a  conscientious 
difference  from  other  writers  has  been  expressed,  I  have 
not  failed  to  award  merit  where  merit  was  due. 

My  friend  and  former  pupil,  Dr.  Addinell  Hewson,  of 
Philadelphia,  has  consented  to  edit  the  American  edition 
of  this  book,  now  in  course  of  publication  by  Messrs. 
Blanchard  and  Lea ;  and  my  friend  Dr.  von  Haselberg, 
of  Stralsund,  has  kindly  undertaken  the  translation  of  it 
into  German. 

Dublin,  21,  Westland-row, 
June  12,  1853. 




MicAifs  OF  DiAONoeis, 5t 

Statistics  and  Nosology  of  Ear  Disbases, 97 



Diseases  of  the  Membrana  Ttmpani, 210 

Diseases  of  the  Middle  Ear  and  Eustaobian  Tube, 811 

Diseases  op  the  Internal  Ear, 871 

Otorrrcea, 894 



IiTDSZ, 497 






Iotn>di>ctoi7ltaiiaTkionAaral3argciy. — Former  idwim  of  ii!UgiMiiU,«ndgai««l  know- 
ledge of  the  subject. Early  History  of  tbe  Art— Writings  of  the  Andents  tna 

Hippocralea  to  Gslen.— Discoveries  of  the  AnUomisU  of  thB  aiteenth  (Hitiiiy.— Irish 
'TrusUtloDS.—HercarisUs.^InstnicliailDrUieDofuidEhimb — Hearnios. — JatiO' 
ductioD  ortheSpe<:nliuiib7Fsbridas._BoDet  snd  Da  Verney — Kennedy.— Eusta- 
diim  CUfaeteriBD  by  Gnyot — English  AoiiOs :  Clelud  sod  W«lhuj.— la^Aerin.— 

DfgTSTen. VsIssIts  sod  Cassebohm. — Sims  snd  the  London  Hedkal  Sode^ — 

Gnbun  snd  Elliott. Quacks  and  Quackerf. Perfoiation   of  Histoid  Process^ — 

Oieselden. — Porfontioa  of  tbe  Membrana  Tj-mpani  liy  Sir  A.  Cooper — Saunde™. 
— Outii  and  his  (bOowera ;  Stephensan,  WilUams,  Wright,  Webster,  Hc?'""!^.  *^ 
Gaidoer— BachansD,  Esrk,  Tod,  Swan  and  Canrell — The  French  School ;  Laennec, 
Itsrd,  and  Deleau.— Ths  Germaii  School:  Eruner,  SchmaU,  Lincke,  snd  Prsnk — 
The  Hodem BngUsh  Scbool:  Toynbee,  Pitcher,  Whaiton  Jone^  Williams,  Teanley, 
Harvey,  Dnlton,  and  Waketey. — Tamboll  and  Ms  Boviewen.— Beqdsite*  fin  an 
Anrsl  SorgeoD,  and  what  Aural  Sarger;  can  etftct. 

XN  the  following  Treatise  I  purpose  writing,  for  the  information 
-*~  of  practitioners  and  studenta  in  medicine,  the  history,  symp- 
toms, causes,  mode  of  treatment,  and  results  of  the  moat  frequent 
and  remarkable  diseasesof  the  Ear.  With  rospeot  to  my  competency 
to  this  task,  I  have  but  to  remark,  that  I  have  had  very  ample  op- 
portanities  for  studying  these  diseases  during  the  last  tea  yean 
in  an  extenmve  practice,  and  in  the  management  of  a  large  public 
institution  in  Dublin,  for  a  long  time  the  only  one  of  the  kind 
open  to  the  student  where  clinical  and  practical  instruction  in 
Aural  Surgery  ma  delivered  in  Great  Britua. 


This  work  is  the  result  of  the  experience  thus  acquired.  De- 
tached portions  of  it,  clinical  lectures,  and  cases  observed  at  St. 
Mark's  Hospital,  have  already  appeared  in  the  periodicals  of  this 
country,  and  some  of  these  essays  have  been  translated  and  pub- 
lished separately  on  the  Continent.  All  these,  together  with  much 
additional  information  gleaned  since  their  publication,  are  em- 
bodied in  this  book,  which  does  not  profess  to  be  a  complete  sys- 
tem of  Aural  Surgery,  giving  a  full  description  of  all  the  diseases  of 
the  Ear  which  have  been  recorded  by  authors ;  but  is  intended 
to  supply  the  reader  with  a  practical  treatise  on  the  most  frequent 
and  urgent  affections  of  the  organ  of  hearing,  and  those  that  I  my- 
self am  best  acquainted  with.  It  may,  therefore,  be  regarded  some- 
what in  the  light  of  a  monograph,  a  form  of  publication  peculiar 
to  this  School,  and  one  generally  containing  more  useful  and  prac- 
tical information  than  either  a  large  systematic  work  or  a  manual. 

In  studying  the  diseases  of  the  Ear,  my  object  has  been  to 
take  as  a  basis  the  principles  of  pathology :  and  to  reduce  their 
treatment,  local  as  well  as  general,  to  the  recognised  rules  of  mo- 
dem therapeutics  and  scientific  surgery ;  but,  above  all,  I  have 
laboured  to  divest  this  branch  of  medicine  of  that  shroud  of 
quackery,  medical  as  well  as  popular,  with  which,  until  lately,  it 
has  been  encompassed. 

Country  friends  often  ask  me,  "  Have  you  found  out  any  new 
cure  for  deafness  T  I  do  not  profess  to  invent  or  introduce  new 
remedies.  I  try  to  make  the  well-established  rules  of  practice  in 
the  treatment  of  other  organs  applicable  to  the  management  of 
aural  diseases.  Like  most  students,  I  was  taught  during  my  ap- 
prenticeship theoretically  to  believe,  and  practically  to  observe, 
that  we  *'  knew  nothing  about  the  diseases  of  the  organs  of  hear- 
ing." This  was  the  dictum  honestly  expressed  by  the  "  heads  of 
the  Profession," — men  from  whom  the  public  were  willing  to  re- 
ceive a  fearless,  candid  opinion,  either  immediately  on  being  con- 
sulted, or  after  a  few  trials  of  the  "ordinary  means;"  to  wit, 
syringing  with  hot  water  and  soap,  either  Castile,  soft,  yellow,  or 
old  brown  Windsor,  in  the  hope  that  the  deafness  or  the  noise  in 
the  ears  might  arise  from  a  collection  of  hardened  wax ; — then 
setting  the  digestive  organs  to  rights  by  purgation,  and  a  '<  course 


of  bitters,"  lest  the  affection  might  be  "  owing  to  the  stomach." 
The  human  stomach  has  much  to  answer  for  in  deranging  the 
system  generally,  no  doubt;  but  the  mischief  of  which  it  is  daily 
accused,  as  every  one  extensively  engaged  in  practice  is  well 
aware,  is  beyond  belief.  There  is  scarcely  a  disease  which  we 
treat,  no  matter  how  local,  upon  which,  if  we  question  the  patient 
as  to  its  duration,  that  he  will  not  say,  "  Oh  I  it  is,  indeed,  of 
pretty  long  standing,  but  I  was  waiting  to  have  my  stomach 
put  to  rights,  as  I  am  told  I  am  very  bilious."  Next  in  order, 
blistering  behind  the  ears  is  tried,  in  order  to  draw  away  some 
peccant  humour  that  had,  perhaps^  accumulated  round  the  deli- 
cate organ  of  hearing.  These  and  such  like  methods  failing  to  give 
relief,  stimulants,  often  of  a  very  acrid  nature,  are  poured  into 
the  external  auditory  passages,  either  to  restore  the  secretion, — un- 
der the  impression  that  what  is  a  mere  attending  symptom  is  the 
disease, — or  to  excite  or  rouse  the  dormant  nervous  power;  and 
hot  tinctures,  turpentine,  creasote,  and  pungent  essential  oils  are 
iCpplied  to  the  external  surface  of  the  tympanal  membrane  with- 
out mercy.  Some  practitioners  resort  to  more  palliative  means, 
recommending  some  warm  almond  oil  to  be  dropped  into  the 
ear  at  bedtime,  or  eau  de  Cologne  to  be  rubbed  upon  the  side  of 
the  cheek  adjoining  the  auricle,  at  the  same  time  advising  a  lit- 
tle black  wool  to  be  retained  in  the  meatus,  in  order  to  preserve 
the  organ  from  cold.  To  give,  however,  fair  play  to  the  latter 
remedy,  it  should  be  prescribed  in  full,  and  according  to  the 
old  popular  superstition,  but  one  which  is  still  extensively  re- 
sorted to, — the  wool  should  be  procured  from  the  left  fore-foot  of 
a  six  years'  old  black  ram !  Some  advise  a  slice  of  fat  bacon  to 
be  inserted  into  the  meatus  every  second  night;  and  glycerine 
is  now  the  fashionable  remedy.  All  these  means  having  failed 
to  give  relief,  the  patient  is  frequently  recommended — an  easy 
mode  of  getting  rid  of  him — to  give  galvanism  and  electricity 
a  fair  trial ;  and  if  they  do  not  succeed,  change  of  air  and  scene, 
sea>bathing,  or  a  '*  course  of  waters"  at  some  of  the  fashionable 
places  of  resort  for  that  purpose  is  prescribed.  Despairing  of 
relief  from  the  legalized  practitioner,  and  getting  disheartening 



opinions  from  men  of  eminence  and  repute,  we  need  not  wonder 
that  suffering  patients  throw  themselves  into  the  hands  of  quacks 
and  nostrum-mongers. 

Moreover,  the  difficulties  which  beset  the  student  in  ac- 
quiring a  knowledge  of  the  anatomy  of  the  ear,  owing  to  the  ex- 
ceeding minuteness  of  the  organ  itself,  the  great  difficulty  of 
dissecting  it,  from  its  depth,  the  complexity  of  its  structure,  and 
the  small,  hard  bone  in  which  it  is  placed,  as  well  as  the  number 
of  crabbed  names  attached  to  its  different  parts,  all  of  which  have 
made  it  a  sort  of  anatomical  crux,  which  no  one  wishes  to  remem- 
ber longer  than  the  day  after  he  has  passed  his  examination,  have 
conduced  not  a  little  to  strengthen  the  belief  in  the  doctrine  pro- 
mulgated by  his  instructors,  that  little  or  nothing  could  be  done 
to  reach  the  diseases  of  so  delicate  and  intricate  an  organ. 

Now,  notwithstanding  the  remarks  which  we  hear  daily  in 
society,  or  which  we  meet  with  in  the  periodic  and  "  manual**  li- 
terature of  the  day, — that  the  treatment  of  diseases  of  the  ear  is 
an  opprobrium  to  medicine, — the  progress  which  this  branch  of 
medical  science  is  making  is  in  all  probability  as  rapid  as  that  in 
any  other  department  of  the  healing  art.  Among  the  many 
causes  from  which  this  opinion  has  arisen,  there  are  two  which 
must  pre-eminently  attract  the  attention  of  any  person  conversant 
with  the  subject,  or  who  will  calmly  examine  into  the  question. 
The  first  is,  that  heretofore  the  treatment  of  those  diseases  has 
been  committed  to  the  hands  of  the  most  uneducated  quacks  and 
charlatans,  male  and  female, — persons  totally  unacquainted  with 
the  first  rudiments  of  medical  knowledge ;  the  second,  that  me- 
dical men  themselves — most  astute  and  practical  physicians  and 
surgeons  in  all  other  respects — treat  diseases  of  the  ear  certainly 
in  a  manner  that  savours  of  empiricism,  by  prescribing  nostrums, 
of  both  a  local  and  general  character,  which  we  know  they  would 
never  think  of  using  in  similar  forms  of  disease  in  any  of  the  other 
organs  of  the  body.  This  latter  cause  evidently  results  from  want 
of  proper  attention  to  the  subject  in  our  schools,  and  from  the 
practice  of  prescribing  at  random  for  diseases,  the  diagnosis  and 
pathology  of  which  are  generally  unknown. 


To  both  these  causes  may  be  added  others  that,  to  a  certain 
degree,  serve  to  bias  the  public  mind  against  the  treatment  of 
aural  diseases.  In  many  cases,  there  is  either  an  unconsciousness 
of  the  insidious  approaches  of  deafness,  or  an  unwillingness  to 
admit  even  the  possibility  of  such  an  occurrence ;  or,  again,  there 
is  an  apathy,  to  a  greater  or  less  degree,  on  the  part  of  those  af- 
fected with  deafness,  and  a  delay  in  seeking  advice,  which  is 
scarcely  credible.  Persons  who,  if  they  suffer  the  least  inconve- 
nience in  any  of  their  functions,  or  the  slightest  interference  with 
the  due  exercise  or  healthy  condition  of  any  of  the  other  organs 
of  sense,  would  immediately  apply  for  medical  relief,  and  submit 
to  any,  even  the  most  severe  form  of  treatment,  will  patiently 
permit  the  sense  of  hearing  to  be  greatly  impaired,  nay,  even  lost 
on  one  side,  without  making  any  effort  for  ift  restoration.  When 
the  lapse  of  months,  and  even  years,  have  contributed  to  confirm 
disease  and  render  such  persons  incurable,  they  generally  respond 
to  inquiries  with  regard  to  previous  treatment, — that  they  did  not 
like  to  be  '*  tampering**  with  their  ears,  or,  that  they  were  told  no- 
thing could  be  done  for  them. 

It  would  in  no  wise  conduce  to  the  practical  effect  to  which  I 
hope  this  work  may  tend,  to  inquire  into  all  the  causes  of  these 
results:  I  may,  however,  mention,  that  medical  men  themselves 
have  in  part  conduced  to  produce  this  want  of  faith  on  the  part 
of  the  public,  either  by  direct  opinion  as  to  the  incurable  nature 
of  the  disease  or  diseases  known  by  the  symptom  of  deafness,  or 
by  such  futile  treatment  as  broke  down  the  confidence  of  the  pa- 
tient in  any  remedy  for  diseases  of  the  organs  of  hearing.  It  is 
true  that  cases  of  what  are  termed  **  nervous  deafness,**  that  is,  of 
defect  in  the  hearing  function  of  the  acoustic  nerve  in  any  part  of 
the  internal  ear,  from  paralysis  or  other  causes, — or  of  those  por- 
tions of  the  brain  which  preside  over  the  faculty  of  hearing,  or 
give  origin  to,  or  are  connected  with  the  portio  mollis  of  the  se- 
venth pair  of  nerves, — in  fact,  such  cases  as  are  analogous  to 
amaurosis, — are  as  intractable  as  that  disease  of  the  eye; — yet  I 
fear  not  to  reiterate  the  assertion  which  I  made  upon  several  for- 
mer occasions,  that  if  the  diseases  of  the  ear  were  as  well  studied 
or  understood  by  the  generality  of  practitioners,  and  as  early  at- 


tended  to,  as  the  diseases  of  the  eye,  it  would  be  found  that  they 
were  just  as  much  within  the  pale  of  scientific  treatment 

We  have  now  several  special  works  upon  aural  surgery,  as 
well  as  some  valuable  monographs  thereon  in  the  cyclopaedias  and 
periodicals,  yet  it  is  to  be  regretted  that  the  modem  systems  of 
surgery  contain  but  scanty  information  upon  the  subject  of  dis- 
eases of  the  ear.  The  following  passage  from  M.  Druitt's  well- 
arranged  "  Surgeons'  Vade  Mecum**  (which  is  an  exception  to 
the  class)  is  so  apposite  to  the  foregoing  observations,  that  I  in- 
sert it: — *'  Deafness  is  so  common  and  so  distressing  an  infirmity, 
and,  when  of  long  standing,  is  so  incurable,  that  we  cannot  too 
strongly  urge  all  medical  practitioners  to  make  themselves  fami- 
liar with  the  treatment  of  diseases  of  the  ear.  They  should  also 
encourage  their  pati<!hts  to  apply  to  them  for  the  relief  of  Mffht 
and  indpierU  ailments  in  this  organ,  instead  of  allowing  them  to 
go  on  till  they  become  permanently  deaf,  and  then  letting  them 
fruitlessly  seek  relief  from  ignorant  and  mercenary  quacks.** 


In  the  present  day,  when  literature  in  every  Protean  shape  and 
form  has  compassed  the  land,  and  knowledge  may  truly  be  said 
to  run  to  and  fro  throughout  the  earth ;  and  when  the  polyglot 
cyclopsedia  of  the  Press  has  outstripped  in  the  race  all  other  feats 
of  human  prowess  of  the  nineteenth  century,  it  might  be  deemed 
unnecessary  to  follow  the  old  school  system  of  detailing  the  early 
history  of  that  particular  branch  of  medicine  of  which  this  essay 
treats,  were  it  not  that  in  an  art  but  just  emerging  from  the  dark- 
ness, ignorance,  empiricism,  prejudice,  and  superstition,  which  is 
to  a  certain  extent  even  yet  the  condition  of  aural  surgery,  its 
history  not  only  becomes  interesting,  but  practically  instructive. 
Furthermore,  as  this  work  is  not  put  forward  as  a  system  contain- 
ing a  compilation  of  opinions,  or  abounding  in  extracts  and  refe- 
rences, but  is  chiefly  the  result  of  my  own  experience,  the  follow- 
ing notices  of  the  writings  of  others  is  given  with  a  view  of 
directing  the  student  to  tlie  most  accessible  sources  of  infor- 
mation on  the  subject. 


I  might,  with  the  generality  of  writers  upon  the  history  of 
medicine,  commence  with  the  timea  of  Hippocrates,  for  he  makes 
several  allusions  to  the  affections  of  the  organs  of  hearing,  not, 
however,  &a  idiopathic  forms  of  disease,  but  as  symptomatic  of 
other  maladies  of  an  acute  or  chronic  nature ;  but  it  must  be 
borne  in  mind  that  at  that  period  of  medical  science  (and,  I  regret 
to  add,  that  it  has  in  a  great  part  descended  to  the  present  day) 
the  affections  of  the  ear,  whether  functional  or  organic,  were 
spoken  of,  lectured  on,  written  of,  and  described,  not  according 
to  the  laws  of  pathology  which  regulate  other  diseases,  but  by  a 
single  symptom,  that  of  deafness.  "  If,"  says  Dr.  Kramer,  "  I 
mention  that  the  treatment  of  deafness  (viz.  as  it  occurs  as  a  func- 
tional disorder  only  of  the  ear,  without  any  perceptible  external 
alteration  of  the  organ)  merely  consists  of  not  washing  out  the 
ear,  but  cleansing  it  with  wool,  dropping  in  oil,  directing  the  pa- 
tient to  walk  out,  rise  early,  drink  white  wine,  abstain  from  salads, 
and  allowing  him  to  eat  bread,  and  such  fish  as  inhabit  rocky 
shores,  I  shall  have  collected  all  that  is  of  most  importance  to 
give  an  idea  of  acoustic  medicine  at  that  time." 

To  CelsuB,  the  successor  of  Hippocrates,  we  are  indebted  for 
the  first  acknowledgment  of  the  specific  or  independent  forms  of 
aural  disease;  for  having  introduced  the  practice  of  ocular  in- 
spection of  the  auditory  canal ;  and  for  some  general  rulee  for  the 
treatment  of  the  inflammatory  affections  of  the  organs  of  hearing. 
But  this  advance  in  aural  medicine,  which  we  owe  to  Celsus, 
is  more  than  counterbalanced  by  his  introduction  into  practice  of 
those  stimulating  nostrums  which  were  then,  and  have  been  since, 
applied  to  the  membrana  tympani  without  discrimination;  and 
many  of  which  are  mode  use  of  in  the  present  day. 

Gralen  followed  in  the  track  of  his  great  predecessor,  and 
although  he  advanced  somewhat  in  symptomatology,  and  was 
evidently  better  acquwnted  with  the  causes  of  the  inflammatory 
diwases  of  the  ear,  yet  he  and  his  disciples  so  increased  the  num- 
ber of  remedial  agents  which  were  applied  to  the  external  meatus, 
that  we  find  aural  medicine  and  surgery,  toward  the  end  of  the 
fifteenth  century,  but  a  collection  of  hard  names,  unconnected 
symptoms,  fanciful  and  absurd  theories  based  on  causes  the  most 


improbable,  and  a  category  of  medical  subetances  from  the  ani- 
maJ,  mineral,  and  vegetable  kingdoms,  principally,  however, 
composed  of  hot  spices  and  stimulating  applications,  of  which  I 
may  mention  castor,  ox-gall,  garlic,  frankincense,  opium,  nitre, 
euphorbium,  alum,  iron  filings  boiled  on  vinegar,  hellebore,  myrrh, 
and  many  other  such  substances,  each  lauded  by  their  respective 
admirers,  and  extolled  as  panaceas  for  deafness  in  all  its  numerous 
forms  and  modifications;  as  we  find  glycerine  is  at  the  present 
day.  Those  who  still  prescribe  such  nostrums,  and  they  are 
many,  might  consult  with  advantage  old  '*  Gbtbelhover's  Boocke 
of  Physicke,"  printed  in  1559. 

It  would  afibrd  us  neither  literary  interest  nor  practical  utility, 
commensurate  with  the  task,  to  detail  the  notions  concerning  the 
treatment  and  diseases  of  the  ear,  as  they  may  be  found  scattered 
throughout  the  writings  of  Aurelianus,  Paul  of  JEgina,  Razes, 
Serapion,  Hali  Abbas,  Mesue,  and  Dioscorides;  the  works  of  the 
three  latter  of  whom  were  translated  into  Grselic  by  several  distin- 
guished Irish  physicians  from  the  beginning  of  the  fourteenth  to 
the  end  of  the  sixteenth  century.* 

At  the  conclusion  of  the  fifteenth  century  the  anatomy  of  the 
ear  received  a  new  impulse,  by  the  investigations  and  discoveries 
of  some  of  the  most  distinguished  anatomists  and  physicians  of 
that  age,  in  compliment  to  whose  labours  subsequent  writers  gave 
those  parts  names  which  we  retain  to  the  present  day,  as,  the  tube 
of  Eustachius,  the  aqueduct  of  Fallopius,  the  liquor  of  Cotunno, 
and  the  fissure  of  Casserius ;  but  although  these  celebrated  men 
made  the  worid  better  acquainted  with  the  anatomy  of  the  organ 
of  hearing,  and  thus  removed  one  of  the  chief  obstacles  to  the  in* 
vestigation  of  aural  pathology,  their  successors  in  medicine  ad- 
vanced but  little  in  the  diagnosis  and  treatment  of  diseases  of  the 

The  first  special  work  upon  the  ear  that  I  have  been  able  to 
discover  is  that  of  Heumius  Mercurialis,  **  De  oculorum  et  aurium 

*  See  the  author't  Introduction  to  the  memoir  on  Vital  Statistics  in  the  Census  of 
Ireland  for  1841 :  and  also  a  Lecture  on  the  Early  History  of  Irish  Medicine,  deliveied 
at  the  College  of  Physicians,  and  published  in  the  Medical  Gazette  fbr  18th  February, 
1848,  et  9tq. 


qffeetibw  Prcdectiones^^  the  first  edition  of  which  was  published 
at  Frankfort  in  1584.  Mercurialis  was  chiefly  a  compilator  from 
the  works  of  the  Greeks,  Romans,  and  Arabians,  and  as  an  origi- 
nal investigator  deserves  no  credit ;  but  he  collected  all  that  was 
known  and  had  been  written  before  his  day  on  aural  diseases ;  the 
little  he  did  add  was  that  of  a  few  more  nostrumSf  and,  therefore, 
he  may  be  consulted  with  advantage  by  those  of  the  fraternity 
who  still  adhere  to  the  good  old  rule  of  applying  such  remedies  as 
hot  onions  in  acute  inflammations  of  the  meatus  or  tympanum. 

In  the  sixteenth  century  the  attention  of  philanthropists  was 
first  turned  towards  the  lamentable  condition  of  the  deaf  and  dumb. 
Prior  to  that  period,  during  those  ages  wont  to  be  called  enligh- 
tened, and  in  those  countries  styled  civilized  and  even  refined — 
among  the  Egyptians,  Greeks,  Romans,  and  Hebrews,  the  deaf 
mute  was,  and  even  still  in  the  Orient  is,  but  little  removed 
from  the  brute,  and  is  often  employed  for  the  basest  and  most  de- 
grading o£Sce8,  such  as  humanity  in  the  present  day,  in  this  coun- 
try at  least,  shudders  at.  Up  to  that  period  the  deaf  and  dumb 
were  not  considered  susceptible  of  improvement  or  instruction  of 
any  kind,  and  their  very  passions,  unrestrained  by  any  influence, 
human  or  divine,  were  frequently  made  to  minister  to  the  cruelty 
or  sensuality  of  those  around  them.  I  need  not  further  enlarge 
upon  this  subject  here,  as  it  is  considered  at  length  in  the  section 
of  this  work  devoted  to  deaf-dumbness. 

The  first  book  that  treated  of  our  subject  in  the  seventeenth 
century  was  a  posthumous  Latin  work  of  Joseph  Heurnius,  on  the 
diseases  of  the  organs  of  hearing,  published  by  his  son,  the  cele- 
brated Otho  Heurnius,  in  1602.  Lincke,  however,  says  that  he 
was  but  a  compiler.  Heretofore  the  treatment  of  aural  diseases 
consbted,  as  already  remarked,  for  the  most  part,  in  medicinal 
agents  and  empirical  nostrums;  but  in  1646  the  principles  of  sur- 
gery were  brought  to  bear  upon  this  class  of  afiections  by  the 
master-mind  of  Fabricius  von  Hilden.  His  observations  on  the 
extraction  of  foreign  bodies,  on  polypi,  and  other  diseases  of  the 
external  auditory  conduit,  are  well  worthy  of  perusal ;  and  to  him 
is  generally  ascribed  the  invention  of  the  first  speculum  auris,  as 
well  as  the  first  ear  instruments  on  record.     His  speculum  was 


formed  on  the  principle  of  the  common  forcepe-like  instrument 
still  in  use ;  but  from  the  following  passage  in  a  still  older  writer, 
Peter  do  la  Cerlata,  '*  per  inspectionem  ad  aoUm  trohendo  amrem 
et  ampliando  cum  speculo  aui  alio  imtrumenio^  we  are  led  to  be- 
lieve that  means  were  employed  before  his  time  for  examining 
the  external  auditory  passage.  Instruments  of  this  kind,  and  for 
this  purpose,  having  been  once  recognised  and  employed  by  prac- 
titioners, have  since  been  variously  modified,  according  to  the  in- 
genuity of  the  inventor ; — ^yet  their  first  introduction  into  practice 
decidedly  formed  an  epoch  in  aural  surgery.  Fabricius's  obser- 
vations, and  the  description  of  his  instruments,  will  be  found  in 
his  "  Opera  Omnia." 

The  next  work  of  any  merit  that  appeared  in  connexion  with 
aural  medicine  was  published  by  a  Genevese  anatomist,  Theophi- 
lus  Bonet ;  his  observations,  as  they  are  set  forth  in  his  great  work, 
the  *^  Sepulcretum  vel  Chirurgica  Practicay^  were  chiefly  confined 
to  the  pathology  of  the  ear  from  dissection ;  but  in  a  practical 
point  of  view  he  advanced  little  beyond  the  limits  attained  by  his 

Towards  the  conclusion  of  the  seventeenth  century  aural  sur- 
gery received  a  new  impulse  from  the  talents  and  laborious  in- 
vestigations of  the  distinguished  French  anatomist,  Du  Vemey. 
Of  late  it  has  become  the  fashion  to  decry  the  labours  of  this  great 
man — in  my  humble  judgment,  unjustly — for  he  was  far  in  ad- 
vance of  his  time,  and  although  the  pathological  is  not  as  volumi- 
nous, nor  perhaps  as  accurate  as  the  anatomical  part  of  his  writings 
on  the  organ  of  hearing,  still  he  was  a  lucid  painter,  and  a  gra- 
phic describer  of  disease.  He  was  the  first  person  who  arranged 
the  diseases  of  the  ear  according  to  the  anatomical  structures  af- 
fected, as,  into  those  of  the  outer  ear  and  meatus,  those  of  the  mid- 
dle ear  or  tympanum,  and  those  of  the  internal  ear  or  labyrinth. 
From  the  times  of  £ustachius  to  the  period  on  which  we  are  now 
engaged,  we  have  no  work  upon  the  anatomy  of  the  organ  of 
hearing  equal  to  that  of  Du  Vemey,  and  to  this  day  it  may  be 
consulted  with  advantage.  Wo  likewise  are  indebted  to  Du  Ver- 
ney  far  more  than  is  generally  acknowledged,  or,  perhaps,  writers 
are  aware  of,  for  having  given  the  first  impulse  to  anything  like 


a  knowledge  of  aural  anatomy  and  surgery  in  England ;  for  his 
book,  which  was  published  in  Paris  in  1683,  was  translated  into 
English  after  his  death,  and  published  in  London  in  1737,  being 
thus,  though  a  translation,  the  first  special  treatise  in  point  of 
time  upon  aural  medicine  or  surgery  in  our  language.  This  is 
now  very  scarce,  yet  there  can,  I  think,  be  little  doubt  but  that 
Mr.  Saunders  availed  himself  largely  of  it.  However,  to  Du  Ver- 
ney,  and  not  to  Lallemand  and  Itard,  we  are  indebted  for  the  pre- 
judice that  up  to  this  day  exists  with  regard  to  the  treatment  of 
otorrhoea.  But  the  latter  were  the  more  reprehensible,  as  from  the 
age  in  which  they  lived,  and  the  giant  growth  of  medical  know- 
ledge subsequent  to  the  time  of  the  former,  they  should  have 
known  better ;  but  I  believe,  like  many  modern  practitioners,  they 
chose  rather  to  transmit  the  prejudices  of  one  hundred  and  fifty 
years  before,  than  take  the  trouble  of  investigating  for  themselves. 

Without  entering  minutely  into  the  history  of  aural  medicine 
during  the  latter  part  of  the  seventeenth  century,  which,  after  all, 
would  consist  in  the  enumeration  of  the  Latin  writings  of  various 
Continental  authors,  more  curious  than  instructive,  let  us  pass  on 
to  the  penultimate  century  of  our  own  period,  when  aural  medi- 
cine first  dawned  in  Great  Britain. 

Li  1713,  Peter  Kennedy  published  in  London  a  little  work 
styled  "  Ophthalmographia,  or,  a  Treatise  on  the  Eye,^  to  which 
is  added  an  Appendix  of  some  of  the  diseases  of  the  ear,  wherein 
is  observed  the  communication  between  these  two  organs;  the 
latter  part  consists  of  about  ten  pages. 

It  is  remarkable,  that  the  discovery  which  Eustachius  made 
of  the  tube  which  bears  his  name  had  no  practical  influence  upon 
this  branch  of  medicine,  and  that  for  nearly  two  hundred  years 
surgery  made  no  effort  at  availing  itself  of  this  knowledge,  for  the 
purpose  of  remedying  diseases  of  the  ear.  Li  1724,  M.  Guyot,  a 
postmaster  of  Versailles,  proposed  to  the  Parisian  Academy  of 
Sciences  to  inject  the  Eustachian  tube,  by  means  of  a  catheter  in- 
troduced through  the  mouth,  for  the  removal  of  obstructions  in 
that  canal,  and  also  in  the  middle  ear.  It  seems,  however,  that 
the  French  academicians  were  not  sufficiently  aware  of  his  valu- 
able discovery,  or  at  least  proposal,  for  it  is  a  question  whether 
he  ever  performed  the  operation  himself 

12  BH0LI8H  AU&I8T8 — GLBLAHD. 

In  1741,  Archibald  Cleland,  an  English  army  surgeon,  pub- 
lished in  the  Philosophical  Transactions  an  account  of  **  instru- 
ments proposed  to  remedy  some  kinds  of  deafness,  proceeding  from 
obstructions  in  the  external  and  internal  auditory  passages.**  The 
first  of  these  consisted  *'  of  a  convex  glass,  three  inches  in  diame- 
ter, fixed  in  a  handle,  into  which  is  lodged  some  wax  candle^ 
which  when  lighted  will  dart  the  collected  rays  of  light  into  the 
bottom  of  the  ear,  or  to  the  bottom  of  any  cavity  that  can  be 
brought  into  a  straigfu  liner  Insignificant  and  incomplete  as  this 
instrument  of  Cleland  undoubtedly  was,  it  is,  nevertheless,  deserv- 
ing of  our  attention,  inasmuch  as  to  it  may  be  traced  the  subsequent 
inspector  auris  of  Deleau,  of  Itard,  Buchanan,  and  Kramer.  The 
principal  object  of  Cleland*s  inspector  for  throwing  a  stream  of 
artificial  light  into  the  meatus  was  for  the  purpose  of  discovering 
the  presence  of  hardened  cerumen,  which  he  removed  by  means 
of  a  jet  of  medicated  steam,  **  but  if,**  says  he,  '*  this  has  not  the 
desired  effect,  and  the  person  still  remains  deaf,  the  following  in- 
struments are  made  to  open  the  Eustachian  tube;  if  upon  trial  it 
should  be  found  to  be  obstructed,  the  passage  is  to  be  lubricated 
by  throwing  a  little  warm  water  into  it,  by  a  syringe  joined  to  a 
flexible  silver  tube,  which  is  introduced  through  the  nose  into 
the  oval  opening  of  the  duct,  at  the  posterior  opening  of  the  nares, 
towards  the  arch  of  the  palate.**  This  catheter  had  affixed  to  it 
a  shecp*s  ureter,  to  the  other  end  of  which  was  attached  the 
syringe,  **  whereby  warm  water  may  be  injected ;  or  they  will 
admit  to  blow  into  the  Eustachian  tube,  and  so  force  the  air  into 
the  barrel  of  the  ear,  and  dilate  the  tube  sufficiently  for  the  dis- 
charge of  the  excrementitious  matter  that  may  be  lodged  there.** 
He  likewise  used  probes,  of  the  same  size  as  the  catheters,  to  ex- 
plore the  tube.  Cleland  was  either  unaware  of,  or  disbelieved,  the 
account  of  Gxiyot*s  having  introduced  an  instrument  into  his  own 
Eustachian  tube  through  the  mouth,  nineteen  years  before ;  for  in 
his  essay  in  the  Philosophical  Transactions  he  does  not  once  allude 
to  the  circumstance.  To  the  English  surgeon,  however,  is  un- 
doubtedly due  the  merit  of  having  first  introduced  a  catheter  into 
the  Eustachian  tube  through  the  nose,  the  only  certain  way,  I 
believe,  of  performing  such  an  operation. 

In  May,  1755,  Mr.  Jonathan  Wathan  published  a  more  de- 


tailed  essay  in  the  Philosophical  Transactions,  on  **  a  method 
proposed  to  restore  the  hearing  when  injured  from  an  obstruction 
of  the  tuba  Eustachiana.  This  gentleman,  who  seems  to  have 
been  a  good  practical  anatomist,  as  well  as  a  dexterous  surgeon, 
had  an  opportunity  of  making  a  post-mortem  examination  in  a 
case  of  deafness,  wherein  it  was  found  that  both  Eustachian  tubes 
were  "  stuffed  quite  full  of  congealed  mucus.**  If  Cleland  over- 
looked, or  was  unacquainted  with  the  proposed  operation  of  the 
Versailles  postpaaster,  Wathan  seems  to  have  completely  over- 
looked the  more  recent  and  effectual  discovery  of  Cleland;  but  in 
allusion  to  the  post-mortem  examination  to  which  I  have  just  re- 
ferred, he  says,  in  the  commencement  of  his  very  admirable  essay : 
^*  As  all  these  concurring  circumstances  strengthen  me  in  my  opi- 
nion, they  likewise  incited  me  to  make  trial  of  an  operation  that 
was  some  time  ago  proposed  to  the  Academy  of  Sciences  by  M. 
Guyot,  but  the  author  having  never  practised  it,  he  wanted  the 
recommendation  of  facts  to  support  and  enforce  it,  it  was,  there- 
fore, rejected  by  them  as  impracticable.**  And  in  a  note,  he  adds, 
that  Ghiyot  having  recommended  the  introduction  of  it  through 
the  mouth,  which  is  quite  impossible,  *'  Petit  proposed,  and  that 
learned  and  skilful  anatomist,  Mr.  John  Douglas,  first  demonstra- 
ted the  possibility  of  passing  the  probe  through  the  nose  into  the 
Eustachian  tube,  and  to  him  I  freely  acknowledge  myself  indebted 
for  the  hint.**  The  catheter  used  by  Mr.  Wathan  was  not  much 
larger  than  a  common-sized  probe,  and  was  bent  a  little  at  the 
end,  very  nearly  in  the  same  form  as  that  used  by  Kramer,  the 
distinguished  Prussian  aurist;  and  with  this  and  a  syringe  he  in- 
jected and  washed  out  the  Eustachian  tube  and  middle  ear.  There 
can  be  no  mistake  about  the  mode  of  Wathan*s  proceeding,  for  he 
has  given  a  very  good  representation  of  the  operation  in  a  plate 
attached  to  his  essay  in  the  Philosophical  Transactions. 

I  have  dwelt  thus  long  upon  the  introduction  of  instruments 
into  the  Eustachian  tube,  as  that  operation  formed  the  second, 
and,  perhaps,  one  of  the  greatest  epochs  in  the  history  of  this  art, 
because  the  merit  is  due  to  our  own  countrymen,  and  because  the 
English  works  upon  aural  surgery  are  not  sufficiently  explicit 
upon  this  point,  and  many  of  the  Continental  ones  are  altogether 


uninformed  with  regard  to  it,— Dr.  Kramer,  in  his  critical  literary 
review,  being  under  the  impression  that  Guyot  had  really  intro- 
duced the  catheter  through  the  mouth. 

The  essays  of  Cleland  and  Wathan,  imperfect  as  they  were, 
were  decidedly  the  greatest  addition  to  aural  surgery  made  in  the 
eighteenth  century,  and  had  the  discoveries  and  valuable  obser- 
vations of  these  practical  men  been  followed  up  in  England,  it  is 
probable  we  would  now  be  far  in  advance  of  our  Continental 
neighbours.  I  would  strongly  recommend  a  perusal  of  Wathan*s 
paper,  as  the  cases  he  describes  are  most  valuable  in  the  diagno- 
sis of  obstruction  of  the  Eustachian  tube. 

So  early  as  1842  I  was  familiar  with,  and  have  since  frequently 
pointed  out  to  many  of  my  medical  friends  and  pupils  a  peculiar 
form  of  deafness,  in  which  the  mcmbrani  tympani  had  fallen  in 
towards  the  inner  wall  of  the  middle  ear, — had  lost  much  of  its 
vibratory  power,  and  in  which,  wlien  examined  under  a  good  light, 
the  handle  of  the  malleus  may  be  seen  appearing  to  press  outwards 
in  strong  relief.  In  this  affection,  which,  I  have  reason  to  believe, 
is  very  often  mistaken  for  nervous  deafness,  we  have  what  may 
be  termed  short  hearing^  from  an  alteration  in  the  vibratory  mem- 
brane of  the  car,  in  like  manner  as  we  have  short  riffhtedness^  or 
myopia,  sometimes  arising  from  a  peculiar  alteration  in  the  curve 
of  the  cornea.  I  find,  however,  upon  carefully  perusing  the  pa* 
per  of  Cleland,  that  he  had  some  idea  of  what  I  have  here  de- 
scribed, and  of  its  being  produced,  as  I  have  known  it  to  be  in 
some  cases,  by  accident.  *'  There  is,""  he  says,  "  another  kind  of 
deafness,  which  proceeds  from  a  violent  clap  of  thimder,  noise  of 
a  cannon,  or  the  like.  In  this  case  it  is  probable  that  the  position 
of  the  membrana  tympani  is  altered,  being  forced  inwards  upon 
the  small  bones,  and  so  becomes  concave  outwardly.  In  this  case 
no  vibration  of  sound  will  be  communicated  to  the  drum  until  the 
membrane  has  recovered  its  natural  position."* 

During  the  remaining  half  of  the  eighteenth  century  I  have 
little  to  record ;  the  art  does  not  appear  to  have  advanced  a  single 
step,  either  in  Britain  or  any  other  part  of  Europe,     Books  and 

*  Philosophical  Transactions,  vol.  xll.  part  ii.  p.  850. 


essays  were  written,  no  doubt,  but  their  authors  added  little  to 
the  labours  of  their  predecessors.  The  great  majority  of  these 
writings  emanated  from  the  German  press,  as,  for  instance,  those 
of  Gniditsch,  Wildberg,  Milloradovics,  Kritter,  Amemann,  and 
Lentin.  Of  the  French  school  may  be  mentioned  Desmonceaux 
and  Leschevin ;  the  writings  of  the  latter  will  be  found  in  the 
Memoirs  of  the  Royal  Academy  of  Surgery  of  Paris  for  1763. 
Having  lately  had  occasion  to  examine  this  dissertation,  which 
was  undoubtedly  the  best  of  its  day,  I  am  bound  to  say  that  the 
lavish  praise  bestowed  upon  it  by  the  French,  and  the  severe 
criticisms  of  the  German  writers,  within  the  last  few  years,  were 
alike  unmerited. 

Up  to  the  close  of  the  eighteenth  century  no  special  work 
upon  the  diseases  of  the  ear  had  appeared  in  England,  with  the 
exception  of  the  translation  of  Du  Vemey,  to  which  I  have 
already  alluded.  English  works  have,  it  is  true,  been  enumerated 
by  foreign  writers,  but  they  were  not  written  upon  the  diseases, 
properly  so  called,  but  on  the  congenital  defects  of  the  organs  of 
hearing.  These  I  have  specified  in  that  portion  of  the  work  re* 
lating  to  the  instruction  of  the  deaf  and  dumb. 

In  1788  Dr.  Peter  Degravers,  who  styled*  himself  Professor  of 
Anatomy  and  Physiology,  published  in  Edinburgh  ''  A  Treatise 
on  the  Human  Ear,**  as  an  Addenda  to  the  second  edition  of  his 
^*  Physico-Medical  and  Chirurgical  Treatise  on  the  Human  Eye." 
This  tract  consists  of  62  pages,  and  is  divided  into  three  Parts: — 
The  Anatomical  Exposition ;  The  Physiological  Inquiry  into  the 
Origin  of  Sounds ;  and  the  external  and  internal  Disorders  of  the 
Ear.  The  work,  though  very  much  beneath  that  of  the  author^s 
Observations  on  the  Diseases  and  Operations  of  the  Eye,  is  yet 
intelligible  enough,  and  came  up  fully  to  the  state  of  knowledge 
on  aural  surgery  at  that  time.  It  is  generally  believed  that  Sir 
Astley  Cooper  was  the  first  person  who  perforated  the  membrana 
tympani.  Degravers,  however,  tells  us  in  his  essay  that  he  com- 
pletely removed  the  tympanal  membrane  in  one  case ;  and  again 
he  says : — *'  I  incised  the  membrana  tympani  of  the  right  ear  with 
a  sharp,  long,  but  small  lancet.   I  left  the  patient  in  that  state  for 


some  time,  and  afterwards  observed  that  it  had  re-united 

I  incised  again  the  membrani  tympani  of  the  right  ear  but 
eniciallj ;  and  on  removing  the  parts  of  the  membrane  incised,  I 
discovered  some  of  the  ossicula,  which  I  brought  out." 

During  the  eighteenth  century  the  anatomy  of  the  organ  of 
hearing  was  further  studied  by  Valsalva,  in  his  work  **  De  Auie 
Humana  Tractatus,**  published  at  Bonn  in  1704 ;  and  by  I.  F.  Gas- 
scbohm,  whose  book,  **  Tractatus  Quatuor  Anatomici  De  Aure 
Humana,  Tribus  Figurarum  Tabulis  lUustrati,**  appeared  in  1734. 
These  writings,  with  subsequently  those  of  Scarpa,  Soemmering, 
and,  in  later  times,  of  Arnold,  have  rendered  the  anatomy  of  the 
organ  of  hearing  very  complete.  Mr.  T.  Wharton  Jones  has  embo- 
died all  that  was  known  upon  the  subject  when  he  wrote  the  arti- 
cle ^'  Organ  of  Hearing**  in  the  Cyclopaedia  of  Anatomy  in  1838. 

The  members  of  the  Medical  Society  of  London,  instituted  in 
1773,  and  composed  of  the  physicians,  surgeons,  and  apothecaries 
of  that  time,  were  not  insensible  to  the  low  condition  in  which 
aural  medicine  stood  toward  the  end  of  the  last  century,  and  in 
their  valuable  memoirs  will  be  found  some  scattered  notices  upon 
the  diseases  of  the  ear,  from  the  pens  of  the  president.  Dr.  Sims, 
as  well  as  from  Mr.  Houghton,  Dr.  Zeucker,  a  Prussian,  and  Dr. 
Roslct  of  Ostend.  Most  of  these  papers  contained  post-mortem 
examinations  of  cases  of  deafness,  a  practice  that,  with  the  ho- 
nourable exception  of  Mr.  Toynbee,  has  not,  I  regret  to  say,  been 
followed  up,  and  very  much  to  the  detriment  of  aural  medicine. 
In  Dr.  Sims*  essay  he  entered  into  a  physiological  discussion  re- 
garding the  nature  of  the  Eustachian  tube,  the  object  of  which 
was  to  show,  that  while  we  heard  all  external  sounds  through  the 
meatus  cxternus,  we  were  conscious  of  our  own  voice  only  through 
the  Eustachian  tube.  The  practical  part  of  his  paper  is,  however, 
exceedingly  valuable,  particularly  with  respect  to  the  manner  of 
pressing  air  through  the  tube  into  the  middle  ear,  by  closing  the 
mouth  and  external  nares,  and  then  making  a  forced  expiration; 
but  this  had  been  already  explained  by  Cleland  in  1741. 

In  1775  James  Graham  published  in  London  "  Thoughts  on  the 
Present  State  of  the  Practice  in  Disorders  of  the  Eye  and  Ear," 


8yo.  ;  and  in  1780  J.  EUliot  made  his  **  Philosophical  Observations 
on  the  Senses  of  Vision  and  Hearing.^  Still,  at  the  conclusion 
of  the  last,  and  about  the  beginning  of  this  century,  aural  sur- 
gery and  medicine  were  at  a  very  low  ebb,  particularly  in  Great 
Britain.  This  want  of  knowledge  by  the  regular  practitioner 
upon  the  subject  of  diseases  of  the  ear  was,  however,  soon  taken 
advantage  of,  not  only  by  professed  quacks  and  nostrum-mongers, 
but  by  the  electrical,  galvanic,  and  magnetic  doctors  of  that  day, 
who  corresponded  to  the  homoeopaths,  hydropaths,  and  mesme- 
risers  of  the  present.  At  the  period  to  which  I  allude,  galvanism, 
magnetism,  and  electricity,  together  with  the  celebrated  metaUie 
tractors^  were  applied  to  the  ears  of  persons  labouring  under  deaf* 
ness,  and  numerous  and  wonderful  were  the  cures  vaunted  in  the 
periodicals  of  the  day,  as  having  been  effected  by  these  remedies; 
— cures  almost  equalling  those  lately  said  to  be  performed  on  the 
eye  by  prussic  acid :  while  secret,  but  never-failing  acoustic  drops, 
stimulating  embrocations,  and  the  like  impostures,  were  pawned 
upon  the  public  by  all  those  who  had  ingenuity  and  effrontery 
enough  to  make  money  after  that  fashion.  And  here  let  us  for  a 
moment  digress  from  the  direct  course  of  our  subject  to  answer  a 
question  that  is  often  propounded — Why  is  it  that  the  empiric 
and  the  pretender,  either  licensed  or  unlicensed, — for  in  these 
days  there  are  as  many  and  as  impudent  quacks  with  as  without 
diplomas, — why  is  it,  one  is  ofl;en  asked,  that  the  charlatan  fre- 
quently succeeds  in  practice  better  than  the  honest  practitioner? 
By  the  term  success,  we  do  not  mean  professional  success  in  his 
arty  but  pecuniary  success  in  life,  and  esteem  among  those  with 
whom  money  ''makes  the  man."  Now  although  we  cannot 
alwajTS  answer  this  query,  nor  would  the  same  explanation  be  ap- 
plicable to  every  instance,  we  can,  however,  assert  one  fact,  which 
in  a  great  measure  contributes  to  the  success  of  the  quack,  and  it 
is  this, — the  hearty  response  of  his  patients  to  the  lesson  picked 
up  from  the  showman — ^^  speak  a  good  word  to  your  friends  out- 
ride." Let  any  well-educated,  honest  practitioner  be  called  on  to 
treat  an  urgent  and  alarmingly  dangerous  case,  where  insidious 
death  stands  at  the  sick  man  s  door — let  him  bring  all  the  power- 
ful acquirements  of  long  years  of  patient  study  and  observation 


of  disease — his  anatomical  and  pathologrical  knowledge-— an  eye 
practised  to  disease,  and  a  head  stored  with  the  sound,  rational, 
scientific,  practical  principles  of  his  art — let  him  add  to  this  the 
kindness  of  a  friend,  nay,  often  the  benevolence  of  a  bene&ctor— - 
let  him  pass  anxious  days  and  sleepless  nights  watching  each  turn 
of  disease  in  his  patient,  and  ministering  to  every  of  the  many 
wants  that  attend  the  bed  of  lingering  sickness — let  him  do  all 
this,  and  finally  (under  Providence)  restore  the  patient  to  health 
and  to  his  friends — stand,  as  we  may  say,  between  the  living  and 
the  dead,  beckon  back  the  approaching  king  of  terrors,  and  give 
again  to  society  a  valuable  life,  and  to  the  trembling,  anxious  fii- 
mily  their  only  earthly  means  of  support — what  is  his  reward? 
He  is,  generally  at  least,  paid  his  fee,  and  the  patient  and  his 
friends  are  generous  enough  to  say  they  feel  grateful  for  all  his 
kind  attention,  for  we  will  not  curtail  it  of  whatever  good  feel- 
ing may  be  shown  on  the  occasion.  But  compare  this  with  a 
patient  who  imagines  he  is  cured  of  an  imaginary  disease  by  a 
water  doctor,  or  an  atom  doctor,  an  electro-biologist,  a  mesmeriser, 
or  a  magnetiser, — is  he  not  immediately  converted  into  a  partisan? 
— does  he  not  become  a  missionary  for  the  nostrum-monger? — 
does  he  not  go  about  from  house  to  house  detailing  the  miracle  of 
his  cure,  the  skill  of  the  doctor,  the  horrors  of  the  regular  prac- 
titioner, and  the  great  benefit  conferred  upon  mankind  by  being 
converted  into  hydraulic  machines;  or  expressing  his  surprise 
that  people  will  go  about  their  ordinary  business  '*  clothed  and  in 
their  right  mind,"  like  the  man  from  whom  the  seven  devils  were 
cast  out,  instead  of  being  wrapped  in  a  wet  sheet,  or  enjoying  a 
sitz-bath  for  ten  hours  a  day ;  while  others  will  wait  upon  you 
specially,  to  beg  and  entreat  you  will  not  convert  your  poor 
stomach  into  an  apothecary's  shop  by  taking  all  that  ''  doctor's 
stuff,"  instead  of  procuring  rest  and  ease  to  all  your  ills  by  just 
such  an  anodyne  as  would  be  formed  by  pouring  one  drop  of 
laudanum  into  the  Bosphorus,  where  it  leaves  the  Euxine,  and 
drinking  a  thimble-full  of  the  same  water  where  it  enters  the 
Mediterranean !  But,  not  content  with  this,  these  medical  mia- 
aionaries  abuse  all  regular  practitioners,  and  often  force  (for  hu- 
manity's sake,  as  they  say)  the  charlatan  upon  the  patient,  who 
then  trusts  to  his  address  for  future  fame  and  profit. 


Iq  1793  Jaaser  revived  the  old  operation  of  perforation  of  the 
mastoid  process  for  the  purpose  of  injecting  the  middle  ear;  but 
as  the  success  attending  this  procedure  must  be  very  doubtful, 
and  the  hazard  very  great,  it  is  never  resorted  to  in  the  pre- 
sent day. 

Several  experiments  had  been  tried  by  anatomists  and  phy- 
siologists upon  dogs  and  other  animals,  in  order  to  discover  whe- 
ther the  function  of  hearing  could  be  carried  on  with  a  perforate, 
or  imperfect  membrana  tympani.  These  investigations  upon  the 
iower  animals  being  deemed  inconclusive,  Mr.  Cheselden,  the 
father  of  English  surgery,  proposed  to  experiment  in  this  matter 
upon  the  living  human  subject,  and  for  this  purpose  a  condemned 
criminal  was  pardoned,  on  condition  of  submitting  to  the  opera- 
tion I  but  a  popular  outcry  prevented  its  being  put  in  force  !* 
Some  years  afterwards.  Sir  Everard  Home,  in  his  article  upon 
the  muscularity  of  the  membrana  tympani,  having  expressed  his 
desire  to  know  the  result  of  perforation  or  destruction  of  this 
membrane,  Mr.,  afterwards  Sir  Astley,  Cooper,  published  a  letter 
in  the  Philosophical  Transactions  for  the  year  1800,  entitled^ 
'^  Observations  on  the  Effects  which  take  place  from  the  Destruc- 
tion of  the  Membrana  Tympani  of  the  Ear.**  Although  this 
paper  did  not  advance  our  practical  knowledge  upon  the  subject, 
yet  it  called  the  attention  of  British  surgeons  to  the  treatment  of 
this  important  organ,  and  put  an  end  to  a  very  generally  received 
notion  among  the  profession,  that  hearing  would  be  totally  lost 
OB  the  opening  of  the  membrana  tympani ;  notwithstanding  that 
a  couple  of  hundred  years  ago  it  was  believed  by  anatomists  that 
an  aperture  existed  in  this  structure,  as  a  normal  condition  dur- 
ing life. 

In  the  following  year  Cooper  published  an  essay  in  the  same 
work  on  the  perforation  of  the  membrana  tympani,  as  a  means  of 
removing  dea&iess  caused  by  obstruction  of  the  Eustachian  tube, 

*  This  case  is  referred  to  in  Walpole*8  Reminisceiices,  where  it  is  stated  that  the  cri- 
nmud  was  Cheselden^s  cousin,  and  that  he  was  pardoned  at  the  intercession  of  Ladj 
Snflblk  (ndstrees  to  George  IT.),  who,  being  herself  deaf,  wished  to  have  the  experiment 
tried.  The  surgeon  lost  the  royal  fkyour,  it  is  said,  by  the  dicamstance.  This  story 
auy,  howerer,  be  but  one  of  the  petty  scandals  of  the  day. 



and  a  consequent  want  of  vibration  in  the  tympanal  membfine. 
This  paper  commenced  a  new  era,  and  opened  up  a  wide  field  in 
aural  surgery.  Like  all  discoveries  in  medicine,  howeTer,  it  was 
at  the  time,  and  in  other  hands,  too  frequently  had  recouiae  tO| 
and  often  misapplied.  The  brilliancy  of  this  operation,  and,  in 
some  instances,  its  instantaneous  effects,  urged  men  to  employ  it 
who  were  totally  ignorant  of  its  application,  as  well  as  of  the 
structures  and  diseases  of  the  organs  of  hearing  generally ;  so  that 
it  soon  fell  into  disuse,  and  although  recommended  by  this  high 
authority,  the  superior  instruments  we  now  possess  of  diagnosing 
with  greater  accuracy  the  condition  of  the  middle  ear,  and  its  in* 
temal  faucial  aperture,  by  means  of  the  air-douche,  and  also  owing 
to  the  comparatively  few  cases  of  deafness  9oldy  depending  on 
closure  or  stricture  of  the  Eustachian  tube,  have  rendered  its  pei^ 
formancc  much  less  frequently  necessary  than  was  at  first  sup- 
posed. Hitnley,  Itard,  Deleau,  Fabrigi,  and  others,  improved  and 
modified  the  instruments  and  the  operation  of  Cooper.  This  may 
be  termed  the  third  epoch  in  our  art;  the  two  first  being  the  ap- 
plication of  the  speculum  by  Fabricius,  and  the  introduction  of 
Eustachian  cathcterism  by  Cleland. 

I  cannot  conclude  this  notice  of  Sir  Astley's  improvement, 
without  quoting  the  pertinent  and  judicious  remarks  with  which 
he  closes  his  memoir — advice  and  remarks  which,  I  regret  to  add, 
have  been  but  little  attended  to,  but  which  are  as  applicable  to 
the  present  time  as  they  were  to  the  period  when  they  were  written. 

"  I  hope  others  will  be  induced,"  he  says,  in  alluding  to  the 
success  of  his  operation,  ''  to  second  my  feeble  efforts,  and  to  di- 
rect their  attention  to  a  subject  which  appears  to  be  of  the  highest 
importance,  and  to  have  been  too  much  neglected  by  medical 
men ;  for  a  knowledge  of  the  structure  of  the  ear  is  by  no  means 
general  in  the  profession,  and  still  less  are  its  diseases  understood. 
A  prejudice  has  prevailed  that  the  car  is  too  delicate  an  organ  to 
be  operated  upon,  or,  as  it  is  commonly  expressed,  tampered yn^\ 
and  thousands  have  thus  remained  deaf  for  the  rest  of  their  lives, 
who  might  have  been  restored  to  their  hearing  had  proper  assist* 
ance  been  early  applied.** 

Not  to  burden  the  reader  with  too  minute  and  extended  a 


bibliology  or  critical  review,  I  will  now  compress  the  history  of 
our  art,  with  few  exceptions,  into  the  labours  of  British  aurists. 
The  well-marked  inflammatory  diseases  of  parts  of  the  auditory 
apparatus,  such  as  the  auricle,  external  tube,  and  tympanum, 
were  generally  treated,  by  all  well-educated  surgeons,  as  in  the 
present  day,  by  strict  antiphlogistic  means,  the  local  abstraction 
of  blood,  purging,  and  counter-irritation  ;  but  here  the  judicious 
interference  of  art  ceased ;  and  it  would  have  been  well  if  all  fur- 
ther meddling  had  been  avoided;  but  laudanum  was  regarded 
as  a  panacea  in  all  cases  of  ear-ache,  no  matter  from  what  cause  it 
may  have  arisen ;  and  drops,  oils,  and  liniments,  some  of  them 
of  the  most  caustic  nature,  were,  without  mercy  and  without  dis- 
crimination, poured  into  the  external  meatus  by  those,  who  like 
the  regicide  of  old — 

"  Stole 
With  jidoe  of  coned  hebenon  in  a  vial, 
And  in  the  porches  of  the  ears  did  pour 
The  leperoos  distilment.'* 

first  upon  the  list  of  British  writers  upon  the  acoustic  appa- 
ratus and  its  diseases  stands  John  Cunningham  Saunders,  the 
distinguished  oculist,  and  the  founder  of  the  London  Infirmary 
for  Diseases  of  the  Eye,  on  whose  merits,  as  an  original  observer, 
a  sound  practical  surgeon,  and  a  critical  anatomist,  I  need  not 
expatiate.  His  work,  ^'  The  Anatomy  of  the  Human  Ear,  illus- 
trated by  a  series  of  engravings  of  the  natural  size  ;  with  a  Trea- 
tise on  the  Diseases  of  that  Organ,  the  Causes  of  Deafness,  and 
their  proper  Treatment,**  was  published  in  1806,  and  although, 
as  I  already  said,  he  availed  himself  of  the  labours  of  Du  Vemey, 
still  to  Saunders  we  are  indebted  for  the  first  special  English 
work  of  any  merit  upon  this  subject,  and  to  him  the  various 
charlatans  that  have  ventured  to  set  forward  their  ideas  in  print 
are  indebted  for  the  mine  from  which  they  drew  the  material  of 
their  various  and  voluminous  publications.  Saunders,  as  an 
aorist^  has  been  unjustly  dealt  with :  he  wrote,  not  merely  in  ac- 
cordance with,  but  beyond  the  knowledge  of,  his  time,  and 
Kramer  not  only  criticises  his  work  with  too  great  severity,  but 
denies  it  the  place  which,  in  a  chronological  point  of  view,  it 


deserves.  This  may,  howerer,  be  sccoimted  for  by  Kramei^s  hav- 
ing quoted  from,  as  perhaps  he  only  had  access  lo,  the  third  edi« 
tion,  published  in  1829,  just  nineteen  years  after  Mr.  Sanndas^ 
death.  The  practical  portion  of  the  work  consisted  of  the  history 
and  treatment  of  the  diseases  of  the  meatus  extemus,  and  those 
of  the  tympanum,  of  the  obstruction  of  the  Eustachian  tube,  and 
of  the  diseases  of  the  internal  part  of  the  ear,  to  which  are  added 
cases  of  incipient  nervous  deafness  successfully  treated.  The  plates 
are  worthy  of  inspection,  and  were  evidently  drawn  from  recent 
dissections.  Saunders  possessed,  in  addition  to  his  originality, 
honesty  and  general  attainments  in  the  science  of  anatomy  and 
surgery,  this  great  requisite  for  an  aurist^ — that,  having  also 
applied  himself  to  the  study  of  diseases  of  the  eye,  he  had  thm 
acquired  habits  of  minute  observation  and  delicate  manipulation, 
without  which  no  man  will  ever  attain  to  eminence  in  either 
art.  Moreover,  the  analogy  which  exists  between  the  diseases, 
as  well  as  the  anatomy  and  physiology  of  these  two  organs,  ena- 
bled him  to  bring  to  the  study  of  the  ear  the  rational  principles 
of  medicine  then  established  in  the  treatment  of  ocular  affections. 

For  six  or  eight  years  we  hear  nothing  of  aural  surgery  in 
Qre&t  Britain,  and  our  space  will  not  permit  of  our  even  enume* 
rating  the  names  of  the  different  Continental  writers  for  the  first 
twentyjycars  of  the  nineteenth  century.  Cooper*s  more  extended 
and  more  lucrative  line  of  practice  caused  him  to  relinquish  aural 
surgery, — this,  and  the  untimely  death  of  Saunders,  seem  to  have 
cast  a  veil  over  this  branch  of  knowledge  in  these  kingdoms. 

In  the  years  1815  and  1817  we  find  two  special  works  on  an* 
ral  medicine ;  of  the  first  of  these,  ^*  Dissertatio  de  Aure  Humana  SC 
eju8  Morhis^^  an  inaugural  essay,  published  by  Mr.  Ball  at  Eldin* 
burgh,  there  is  little  even  to  criticise;  and  the  second  was  the 
earliest  work  of  the  since  far-famed  John  Harrison  Curtis.  Let 
us  read  its  high-sounding  title :  '*  A  Treatise  on  the  Physiology 
and  Diseases  of  the  Ear,  containing  a  comparative  view  of  iti 
Structure,  Functions,  and  of  its  various  Diseases,  arranged  acoord- 
ing  to  the  Anatomy  of  the  Organ,  or  as  they  affect  the  external^ 
the  intermediate,  and  the  internal  Ear.**  Let  us  draw  from  the 
writings  of  a  foreigner  the  opinion  that  a  man  of  honesty  and  prad* 


tical  experience  formed  of  this  and  the  author's  subsequent  works;. 
'*  Curtis,"*  says  the  writer,  <*  treats  every  discharge  from  the  ear 
exclusiyely,  and  in  a  summary  way,  by  means  of  astringents;  ob* 
struetions  of  the  Eustachian  tube,  with  emetics  and  perforation  of 
the  membrana  tympani ;  whilst,  in  spite  of  all  the  entreaties  of 
Saissy ,  he  has  never  once  practised  catheterism  of  the  Eustachian 
tube  on  the  living  subject.  He  makes  tinnitus  the  chief  symptom 
of  nervous  deafness,  which  he  treats  with  purgatives,  especially 
calomel,  as  long  as  the  strength  of  the  patient  holds  out.*'  ^'  In  all 
doubtful  cases  the  chief  attention  is  directed  merely  to  ascertain 
whether  the  liquor  Cotunnii  be  partially  or  totally  deficient ! !  or 
whether  hardened  wax  exist  in  the  meatus."*  ^*  In  the  otitis  of 
children  he  sticks  opium  into  the  affected  ear,  &c.,  so  that  through- 
out all  his  writings  nothing  but  the  most  crude  empiricism  is  to 
be  met  with ;  and  yet  among  his  compatriots,  as  well  as  abroad, 
Curtis  generally  possesses  the  reputation  of  being  a  distinguished 
aurist."  And  one  of  the  first  English  medical  periodicals  of  the 
day  thus  expresses  its  admiration  of  the  same  person :  ''Mr.  Curtis, 
in  his  Treatise  on  the  Physiology  and  Pathology  of  the  Ear,  has 
appropriated  the  whole  of  Mr.  Saunders*  essay.  The  exact  words, 
indeed,  have,  in  some  instances,  been  changed,  but  the  plagiarism 
is  too  manifest  to  escape  even  the  most  inattentive  reader.  To 
this  paraphrase  of  Mr.  S.'s  work,  Mr.  Curtis  has  added  some 
things  from  other  authors,  and  some  histories  of  cases  treated  by 
himself  (of  course  all  most  successfully),  and  has  thus  concocted 
a  treatise  which,  with  singular  effrontery,  he  has  put  forth  as  en* 
tirely  of  his  own  composition,  and  as  containing  the  results  of  his 
own  practice.  This  work  has  now,  for  a  period  of  about  twenty 
years,  been  forced  upon  the  attention  of  the  public  by  the  adver- 
tisements of  successive  editions;  and  it  is  a  melancholy  fact,  that 
there  should  have  been  found  editors  of  medical  journals  either 
so  ignorant  or  so  careless  as  to  lavish  commendation  on  such  a 

Almost  in  a  similar  category  may  be  classed  the  writings  of 
Williams,  sumamed  the  nostrum-monger;  and  also  those  of  Ste- 
phenson and  of  Wright,  "  New  Observations  on  the  Diseases  of 
the  Eye  and  Ear,"  1817.  The  latter  followed  something  of  the 
plan   laid  down  by  Curtis,   of  simply  recomposing  the  words 


of  his  first  work ;  for  as  to  new  ideM,  there  were  none,  nor  old 
ones  to  add  them  to.  In  order  to  form  either  a  new  editioo,  or 
a  new  book,  we  find  the  changes  rung  to  the  following  tones  for 
about  ten  or  eleven  years :  '*  An  Essay  on  the  Human  Ear,  its 
Anatomical  Structure,  and  Incidental  ComplaintSi**  1819 ;  ^  The 
Aurist,  or  Medical  Guide  for  the  Deaf;**  1825;  «« Plain  Adviee 
for  all  Classes  of  Deaf  Persons,  the  Deaf  and  the  Dumb,  and  those 
having  Diseases  of  the  Ear,*"  1826, — verily,  this  must  have  been 
a  popular  book ;  "  Observations  on  the  Effects  of  Mercury  on  the 
Organs  of  Hearing,  and  the  improper  use  of  it  in  cases  of  Ner- 
vous Deafness,**  1827;  "On  the  Varieties  of  Deafness  and  Dis- 
eases of  the  Ear,  with  proposed  Methods  of  relieving  them,**  1829. 
To  these  was  added,  *'  The  Present  State  of  Aural  Surgery,**  to- 
gether with  three  or  four  others,  all  by  tlie  redoubted  Mr.  Willing 
Wright  With  these  productions  may  be  classed  those  of  Wd>- 
ster,  Thornton,  and  Fletcher,  works  similar  in  substance  and  com- 
position, although,  perhaps,  not  so  flagrant  in  plagiarism.  Among 
the  writers  of  that  period,  and  with  some  even  down  to  the  pre- 
sent, it  was  usual  to  preface  whatever  they  had  to  offer  to  public 
notice  as  a  euro  for  deafness  by  a  lengthened  description  of  the 
structure  and  physiology  of  the  ear,  copied  from  some  of  the  ge- 
neral or  special  works  upon  anatomy.  Thus,  when  one  of  the 
persons  just  alluded  to  wished  to  advertise  a  new  instrument,  made 
to  fit  the  back  of  the  auricle,  for  the  purpose  of  collecting  sound, 
we  find  that  there  issued  from  the  London  press  in  1836,  *^  A 
new  and  familiar  Treatise  on  the  Structure  of  the  Ear  and  on 
Deafness,  by  A.  W.  Webster,  inventor  of  the  Otaphone,  &c.  &cJ* 
Among  the  illustrations  to  that  work  we  observe  an  ill-executed 
wood-cut,  of  a  very  ugly  and  misshapen  auricle,  but  bearing  the 
attractive  inscription  of  *'  Mozart's  Ear.**  On  perusing  the  text, 
however,  we  discover  that  it  was  not  the  ear  of  the  great  musi- 
cian, but  that  of  his  youngest  son,  **  which  resembled  that  of  his 
father  T  One  specimen  from  the  medical  portion  of  the  book  will 
suffice:  ''The  membrane  of  the  tympanum,  which  I  have  before 
described  as  presenting  the  appearance  of  a  large  opal  bead,  was 
frequently  reduced^  both  in  size  and  colour,  to  the  resemblance  of 
a  mustard  seed^  the  burning  substances  which  had  been  put  wiikin 
the  ear  having  effected  that  change/' 


But  it  was  not  alone  among  the  instrument  venders  and  itine- 
rant aurists  that  ignorance  and  quackery  were  to  be  found.  About 
eight  years  ago  I  was  sent  a  book,  bearing  the  following  title, 
but  without  a  date :  "  The  Causes,  Symptoms,  and  Treatment  of 
Nervous  Deafness,  Inflammation  of  the  Eye,  and  Indigestion,  po- 
pularly treated  by  J.  D.  Hepworth,  late  Surgeon  to  the  Leeds 
General  Eye  and  Ear  Infirmary.**  In  the  anatomical  descrip- 
tion he  says,  the  membrana  tympani  is  *'  of  a  dry  and  brittle  tis- 
sue, without  fibres  or  blood-vessels.**  Nervous  deafness  is  ascribed 
to  obstructions  in  the  secretion  of  the  fluid  of  the  vestibule ;  and 
hardness  of  hearing,  following  measles  or  scarlet  fever,  to  chronic 
inflammation  of  the  membrane  of,  and  deposits  of  lymph  within, 
the  semicircular  canals !  Surely  foreigners  might  well  criticise 
English  writers  on  aural  medicine  when  they  read  such  state- 
ments as  the  foregoing. 

Somewhat  of  the  same  character  is  the  work  of  Dr.  Gardner 
on  Deafness,  consisting  of  152  pages,  entirely  devoted  to  the  ana- 
tomy of  the  ear,  with  half-a-page  at  the  end  explanatory  of  the 
contents  of  the  second  part,  upon  the  Pathology  and  Treatment  of 
Diseases  of  the  Ear,  but  which  we  have  not  yet  seen.  This  is  the 
only  book  upon  the  subject  which  has  issued  from  the  Dublin 
press.     It  appeared  in  1828.* 

There  is  one  English  writer  whom  we  would  rescue  from  the 
criticism  which  has  been  already  applied  to  his  predecessors.  In 
1823,  Mr.  Thomas  Buchanan,  an  intelligent  surgeon  of  Hull,  pub- 
lished an  engraved  representation  of  the  anatomy  of  the  human 
ear,  to  which  were  added  some  surgical  remarks  on  Eustachian 
catheterism,  together  with  an  account  of  the  operation  of  punctur* 

*  Its  lengUiy  and  attractiTe  title  runs  thoa :  "  A  Treatifle  on  Deafiiets ;  ita  Canaes, 
PieventioD,  and  Cure ;  the  Physiology  and  Anatomy  of  the  Ear;  the  Uses  of  the  difl^ 
not  parts  for  the  modification  and  conveying  of  Soonds  to  the  seat  of  Hearing ;  the  dif- 
ftnnt  flsweo  of  Diseases  incident  to  the  different  parts,  and  what  class  of  Medicines  are 
best  calcnlatffd  to  restore  the  several  parts  to  their  proper  functions ;  also,  a  representa- 
tioo  of  the  cases  out  of  the  reach  of  human  aid.  The  map  of  the  internal  ear  will  diow 
the  precise  situation  of  the  most  important  parts,  to  fiudlitate  the  study  of  its  anatomy,  and 
slioald  be  rsferred  to  in  the  perusal  of  this  work.  By  T.  Gardner,  Esq.,  M.  D.,  Aurist, 
and  Professor  of  Physiology  of  the  Ear.    Dublin :  Printed  by  J.  M'Mullen,  55,  Ex- 



ing  the  membrana  tympani,  and  concluded  with  a  tynaptioal  ta- 
ble of  diBeases  of  the  ear.  Mr.  Buchanan  put  forward  many  £»1- 
lacies  in  hifl  work,  particularly  with  regard  to  the  physiological 
uses  and  diseases  of  the  external  meatus;  and  in  a  Uterary  point 
of  view  he  seems  to  have  fallen  into  the  snare  almost  peculiar  lo 
English  aurists,  for  within  a  couple  of  years  he  followed  up  wha^ 
ever  success  may  have  attended  his  first  publication  by  producing 
two  other  works,  one,  the  "  Illustrations,"  and  the  other,  **  The 
Guide  to  Acoustic  Surgery ;"  and  in  1828  i^peared  a  fourth  work, 
*'  Physiological  Illustrations  of  the  Organs  of  Hearing,  more  par^ 
ticularly  of  the  secretion  of  cerumen,  and  its  effects  in  rendering 
Auditory  Perception  accurate  and  acute."  Buchanan,  however, 
deserves  our  commendation  and  commands  our  respect  as  being 
the  first  English  writer  who,  since  the  days  of  Saunders  and 
Cooper,  based  his  works  upon  a  knowledge  of  the  principles  of 
anatomy  and  surgery ;  and  to  him  we  are  indebted  for  an  improve- 
ment in  the  inspector  auris,  by  means  of  which,  as  I  have  already 
explained  at  page  12,  artificial  light  may  be  transmitted  through 
the  meatus  to  the  membrana  tympani. 

About  the  year  1820  some  notices  of  aural  diseases  appeared 
in  the  medical  periodicals,  and  foremost  among  the  writers  of  these 
stands  Mr.  Henry  Earle,  whose  short,  but  accurate  and  practical 
observations  upon  some  diseases  of  the  external  meatus,  published 
in  the  London  Medico-Ohirurgical  Transactions,  are  well  worthy 
of  perusal.  The  Lancet  and  Medical  Grazette  likewise  contained 
some  detached  notices,  and  the  details  and  pathological  appearw 
ances  of  several  cases  of  the  diseases  of  the  organs  of  hearing. 

Within  the  last  twenty  years  there  have  appeared  three  small 
works  upon  the  anatomy  and  physiology  of  the  organ  of  hearing, 
by  Mr.  Swan,  Mr.  David  Tod,  and  Mr.  Caswall.  The  first  of 
these,  from  the  originality  of  its  ideas,  and  the  speculative  theoiy 
of  its  author,  justly  attracted  attention  in  an  anatoraico-physiolo- 
gical  point  of  view,  yet  neither  it  nor  the  other  two  with  which 
it  is  associated  should  have  been  enumerated  in  the  history  of  au- 
ral surgery,  but  that  to  each  were  affixed  some  observations  upon 
the  pathology  of  the  ear  generally,  and  its  congenital  defects  in 
particular.     These  observations  are,  however,  crude,  speculative. 


and  unpracticid.  I  may  merely  menUon  one  of  thee^  as  a  siatn- 
ple  of  the  reat:-^Mr.  Tod  proposes  as  a  remedy  for  congenital 
deafness  depending  on  derangement  of  the  structures  in  the  tym- 
panum, the  introduction  of  such  acrid  substances  as  ammonia, 
oantharides,  and  the  mineral  acids,  in  order  to  produce  such  an 
inflammation  as  may  rouse  into  activity  the  dormant  powers  of  the 
parts  contained  within  that  cavity  I 

The  splendid  discoveries  of  Laennec  with  regard  to  the  ste- 
thosoope,  and  the  morbid  or  abnormal  sounds  produced  by  streams 
of  air  passing  over  diseased  structures,  were  not  long  in  being 
employed  as  a  means  of  diagnosis  by  such  of  his  countrymen 
as  had  devoted  their  talents  and  energies  to  the  investigation 
and  treatment  of  diseases  of  the  ear.  Foremost  among  these  stood 
Deleau,*   whose  works  first  established  the  more  general  prac- 
tice in  Europe  of  the  introduction  of  various  medicated  vapours, 
as  well  as  fluid  injections,  into  the  middle  ear,  by  means  of  cathe^ 
terism  of  the  Eustachian  tube,  a  mode  of  treatment  since  so  ex- 
tensively employed  by  Kramer.    But  it  should  not  be  forgotten 
that  similar  means  were  used  in  England  nearly  a  hundred  years 
before  by  Cleland  and  Wathan.    The  labours  of  Itard  are  also 
Worthy  of  attention,  from  the  clearness  and  perspicuity  of  his 
views,  and  firom  his  vast  experience  in  ti^ating  the  inflammatory 
diseases  of  the  external  and  middle  ears,  yet  his  work  is  by  no  ^ 
means  devoid  of  those  prejudices  which,  even  to  the  present  day, 
like  the  amulets  of  a  by-past  age,  still  hang  round  books  upon 
aural  surgery  .f 

To  these  may  be  added  the  works  ofM.  E.  Hubert  Vallerouxi 
the  chief  of  which  is  the  '*  Eiaai  Theorique  et  Pratique  wr  les 
Maladies  derOreOUr    Paris:  1846. 

We  now  turn  again  to  Germany,  where  we  find  aural  surgery 
in  a  higher  condition  than  in  any  other  country  in  Europe.  To 
enumerate  all  the  books  and  pamphlets  on  diseases  of  the  ear 

•  "  Becherdies  Pratiqiie  sor  les  MalAdies  de  rOi«ill«,  et  lur  1e  DeveUoppement  d« 
rOreille  et  de  la  parole  chez  les  Surds  Muets.**    Paris :  188S. 

t**TriiledC0  Maladies  deUOreilleetder Audition.'*  Tom.  iL  Paris.  Second  edi- 


which  had  emanated  from  the  Gtennan  pieas  ainoe  1830  would 
occupy  unneceaaary  space  in  this  limited  outline,  but  the  princi- 
pal were  the  writings  of  Kramer,  Lincke,  Schmalz,  and  Frank. 
Dr.  W.  Kramer,  of  Berlin,  published  his  first  work,  An  Easay 
on  Chronic  Deafness,  in  1832,  and  thb  he  afterwards  enlarged 
and  published  as  a  System  of  Aurat  Surgery  in  1836,  **  Die  JBt- 
kenntniss  und  Heilunff  der  OhrefJcrankheUmJ^  In  the  following 
year  it  was  admirably  translated  into  English  by  Dr.  J.  R.  Ben- 
nett,  and  is  decidedly  the  best  special  treatise  on  the  subject 
which  has  yet  appeared  in  this  country,  where  it  exercised  a 
most  salutary  influence  upon  the  diagnosis  and  treatment  of  dis- 
eases of  the  ear.  *'  In  these  and  other  signs,"  writes  the  reviewer 
of  Dr.  Bennett*8  translation  in  the  British  and  Foreign  Medical 
Review  for  1848,  ''  we  think  we  see  clear  indications  of  a  new 
era  in  acoustic  (?)  surgery  in  thb  country,  when  learning  aifd 
science  shall  assert  their  rights,  and  the  despicable  ignorance  and 
impudent  empiricism  which  have  hitherto  prevailed  shall  be  le- 
duced  to  their  proper  level.***  The  truth  of  this  prediction  has 
since  been  verified.  Dr.  Kramer  subsequently  published  two 
other  works  upon  the  ear, — **  Beilrdge  zur  Ohrenheiikunde^  in 
1845,  the  major  part  of  which  relates  to  the  statistics  of  aund 
diseases, — to  which  I  shall  have  occasion  to  refer  in  the  next  chap> 
ter,— and  '« Die  Ohrenheilkunde  in  den  Jahren  1849  und  1850.* 
Independent  of  the  luminous  descriptions,  the  critical  acumen, 
and  practical  observations,  and  the  consequent  absence  of  quack« 
ery,  with  which  all  Dr.  Kramer's  writings  abound,  the  chief  new- 
ness and  originality  of  the  work,  which  has  been  translated  into 
our  language,  consisted  in  the  details  of  cases  of  nervous  deafness, 
so  called,  said  to  have  been  cured  by  the  introduction  of  etherous 
vapour  and  other  gaseous  substances,  by  means  of  an  air-pump, 
into  the  middle  car,  though  the  Eustachian  tube.  By  thus  fumi- 
gating the  mucous  membrane  lining  the  drum,  it  was  said  that 
the  dormant  powers  of  the  auditory  nerve  were  stimulated  to  a 
healthy  action  I    As  a  means  of  diagnosis  the  instrument  is  very 

*  In  Uie  adminble  periodical  from  which  the  above  has  been  extracted  wiU  be  Iboad 
■everalleanMd  artidea  on  aoral  medicine. 


valuable,  although  the  cases  in  which  it  is  required  are  compara- 
tively few ;  but  as  a  therapeutic  agent  the  Eustachian  pump  has 
been  much  overrated,  and  if*  benefit  to  any  extent  has  been  de- 
rived from  introducing  medicated  vapours  into  the  middle  ear,  it 
is  more  than  probable  that  the  deafness  was  in  such  cases  caused 
by  inflammation  of  the  cavity,  upon  the  investing  membrane  of 
which  those  minute  ramifications  of  the  tympanic  plexus  of  the 
glofiso-pharyngeal  nerve  are  distributed,  as  had  been  previously 
remarked  by  Mr.  Swan.  Ten  years'  trial  and  experience  has  not, 
in  other  hands  at  least,  verified  the  anticipations  which  were  en- 
tertained from  a  perusal  of  the  Berlinese  aurist's  opinions.  The 
rage  for  fumigating  ears,  as  well  as  eyes,  has  for  the  present  passed 
by.  It  has  not  been  found  that  the  vapour  of  ether  cures  cases  of 
paralysis  or  impairment  of  the  function  of  the  auditory  nerves,  no 
more  than  the  fumes  of  prussic  acid  afford  relief  in  amaurosis,  or 
remove  cataracts  or  deep-seated  corneal  opacities.  A  new  and 
enlarged  edition  of  Dr.  Kramer's  book  on  the  Nature  and  Treat- 
ment of  Diseases  of  the  Ear  appeared  in  February,  1849,  the 
author  having  been,  he  says,  induced,  during  the  revolution  in 
the  Prussian  capital,  to  betake  himself  to  literature  and  the  revi- 
sion of  his  former  writings.  From  the  tone  of  the  remarks  which 
have  been  introduced  into  this  new  edition,  one  is  inclined  to 
think  the  writer's  labours  must  have  been  very  much  interrupted 
by  the  fierce  battie  waging  around  him ;  for  certainly  while  we 
are  unable  to  discover  much  additional  matter  of  value  therein, 
we  are  not  a  little  surprised  at  the  style  of  his  language,  so  un- 
courteous,  and  imsuited  to  a  scientific  subject.  For  myself  I  cannot 
but  feel  complimented  by  having  so  large  a  portion  of  the  inser- 
tions in  the  new  edition  of  this  work  devoted  to  the  consideration 
and  review  of  my  writings  and  opinions ;  but  for  the  sake  of  lite- 
rature and  science,  and  the  friendly  feeling  which  has  so  long 
existed  between  the  Irish  and  German  schools  of  Medicine,  I 
cannot  but  regret  that  my  friend  did  not  discuss  the  questions  at 
issue  in  a  calmer  and  more  philosophic  mood. 

Dr.  C.  6.  Lincke,  of  Leipzig,  has  published  a  voluminous 
work  upon  Ear  Medicine,  consisting  of  two  volumes,  the  first  of 
which,  upon  the  Anatomy,  Physiology,  and  Pathology  of  the  Or- 


gans  of  Hearing,  appeared  in  1837 ;  and  the  8eo(md«  on  the  Mo- 
aology  and  Therapeutics  of  Diaeaaes  of  the  Ear,  was  brooghl  om 
in  1840.  This  ''  ffandbuch  der  T/^earetischm  und  PrakiUeken 
0/trenheilkund6j^  not  having  been  translated  into  the  language  of 
this  country,  is  not  as  well  known  as  it  deserves;  for  although  it 
does  not  contain  much  original  matter,  is  rather  prolix  in  its  lite- 
rary analysis,  and  is,  perhaps,  somewhat  too  minute,  not  to  say 
fanciful,  in  its  division  and  enumeration  of  diseases  of  the  ear, 
yet  it  comprises  all  that  was  known  upon  the  subject  of  aoial 
surgery  at  the  time  it  was  written,  and  is  most  valuable  as  a  work 
of  reference,  exhibiting  great  learning  and  research. 

Another  industrious  compiler  is  Dr.  E.  Schmala,  of  Dresden, 
who  has  written  several  useful  treatises  upon  this  subject,  and 
whose  work  upon  deaf-dumbness,  ^'  Kuee  Gesehiehie  wmd  Star 
tittik  der  TaiAsitimmenafuiaUen  und  da  Taub&tummamiinierriekim 
nebet  vorausgeiehiekten  arztliehen  JBemerkungen  uber  die  Tmfh 
stummkeiit''  was  one  of  the  best  when  it  appeared  in  1830.  The 
other  principal  works  of  this  author  are  his  *'  Effahnmgen  uber 
die  Krankkeiten  des  Gehores  und  xkreHeilung^  published  in  1846, 
and  '*  Beitrage  eur  Gekor-und  SprackrHeilkunde^^  in  1848. 

Dr.  Martell  Frank,  of  Wiirtzburg,  issued  in  1845  his  "Pfo^ 
Hiche  AnleUung  zur  JErkermtnisi  und  Behandlung  der  OAroi- 
krankheUen^  &c.,  an  admirable  digest  of  the  subject,  abounding 
in  references,  but  not  containing  much  original  matter.  Like  the 
works  of  the  two  former  authors,  it  will  be  principally  useful  as  a 
work  of  reference ;  and  it  abounds  in  wood-cuts,  illustrating  the 
different  instruments  used  in  aural  surgery. 

I  shall  now  conclude  this  review  with  some  notices  of  modon 
English  writers.  In  1837  the  Medical  Society  of  London  offered 
a  prize  for  the  best  essay  on  **  The  Structure,  Economy,  and 
Diseases  of  the  Ear."  This,  together  with  the  Fothergillian  Me- 
dal, was  awarded  to  Mr.  Pilcher  of  London,  who  in  the  following 
year  published  his  essay  as  **  A  Treatise  on  the  Structure,  Eco- 
nomy, and  Diseases  of  the  Ear.**  It  is  divided  into  three  parts :  the 
Anatomy  and  Physiology,  the  Abnormal  Conditions  and  Malfor- 
mations, and  the  Diseases;  the  latter  consisting  of  171  pages; 
a  truly  practical  work,  divested  of  all  those  absurdities  which, 


wilh  the  exception  of  those  of  Saunders  and  Buchanan,  charac- 
terized its  predecessors  in  the  British  metropolis.  The  profession 
would,  I  am  sure,  in  the  subsequent  editions  of  this  work,  rather 
■ee  the  author^s  opinions  supported,  and  his  descriptions  illustrated, 
by  cases  occurring  under  his  own  observation,  of  which  he  must 
have  many,  than  those  supplied  by  his  friends,  or  extracted  from 
periodicals.  If  Kramer  led  the  profession  to  expect  too  much 
from  the  use  of  the  air-pump,  and  the  introduction  of  medicated 
vapour,  I  cannot  but  think  Mr.  Pilcher's  practice  of  washing  out 
the  middle  ear  by  means  of  a  syringe  attached  to  a  catheter  passed 
through  the  Eustachian  tube  is,  to  say  the  least  of  it,  unneces- 
sary ;  and  his  method  of  exploring  that  passage  and  the  tympa- 
num, by  introducing  whalebone  sounds  and  silver  stylettes,  is 
rather  heroic.  The  author  says :  ''  The  surgeon  must  be  specially 
eareful  not  to  injure  the^ssicula,  the  avoidance  of  which  will  re- 
quire great  caution,  passing  as  they  do  across  the  cavity ;  the 
•ftylette  must,  therefore,  ju^  reach  the  tympanum,  without  enter- 
ing it;**  but  we  are  not  informed  by  what  tactua  eruditus  this  is 
tShcted.  Mr.  Pilcher*s  treatise  is  illustrated  in  both  the  anatomi- 
cal and  pathological  departments ;  but  not  in  accordance  with  the 
•tate  of  art  in  Great  Britain  fourteen  years  ago ;  of  which  the 
relation,  size,  shape,  and  bearing  of  the  Eustachian  tube  and 
meatus  auditorius  externus,  in  Plate  IX.  fig.  1,  is  an  example* 
It  is  very  difficult  to  have  a  faithful  drawing  made  of  die  appear- 
ance of  the  membrana  tympani  in  disease ;  in  fact  the  artist  re- 
quires to  be  well  acquainted  with  aural  pathology  before  he  can 
be  perfectly  successful ;  and  therefore  this  defect — which  has 
not  as  yet  been  remedied — is  one  of  the  causes  which  retard  the 
progress  of  aural  medicine.  It  is  therefore  of  great  importance 
that  the  appearance  of  the  external  surface  of  the  membrana 
tympani,  which,  from  its  concealed  position,  very  few  persons 
ever  see,  should  be  well  described,  both  in  a  healthy  and  diseased 
state,  and  all  the  peculiarities  of  the  former  accurately  recorded. 
One,  consequently,  regrets  that  Mr.  Pilcher  did  not  record  the 
ordinary  appearances  of  this  structure,  as  seen  with  a  stream  of 
well-directed  sunlight  upon  it,  when  describing  its  anatomical 
lela^ns  and  connexions ;  in  one  point  of  which  latter  I  must 


differ  with  him,  and  thb  point  it  is  necessary  to  allude  to^  because 
it  really  is  of  practical  importance  to  those  commencing  the  study 
of  aural  diseases,  and  having,  perhaps,  to  observe  for  themaelveSf 
without  the  benefit  of  clinical  instruction,  to  know,  that  in  the 
usual  erect  position  of  the  human  subject,  the  manubrium  of  the 
malleus,  which  is  the  chief  object  on  which  the  eye  first  rests  in 
examining  the  ear,  is  twt  ''inclined  a  little  forwards,  but  par- 
ticularly inwards,**  but  proceeds  downwards  and  backwards.  As 
it  is  not  intended  to  discuss  the  opinions  of  authors  at  any  length 
in  the  practical  and  descriptive  portions  of  this  work,  these  ob- 
servations will  not,  I  trust,  be  deemed  inappropriate  here. 

In  1840  Dr.  J.Williams  published  a  '<  Treatise  on  the  Ear; 
including  its  Anatomy,  Physiology,  and  Pathology  ;**  which  was 
originally  written  as  an  Inaugural  Dissertation  at  Edinburgh,  and 
for  which  a  gold  medal  was  awarded  the  author  by  the  Senatus 
Academicus  of  that  University.  It  is  a  valuable  and  unassuming 
compilation,  well  *'  got  up,"  and  with  good  engravings,  but  it  has 
not  added  much  to  our  stock  of  knowledge  on  the  subject,  and  is 
more  valuable  as  a  book  of  reference  than  a  practitioner*s  guide 
or  student's  manual.  Cooper's  Surgical  Dictionary,  especially 
the  seventh  edition,  published  in  1848,  also  contains  much  curious 
information,  and  quotes  many  remaikable  cases  bearing  upon 
aural  surgery. 

In  the  ninth  Part  of  the  Cyclopedia  of  Practical  Surgery, 
published  in  1841,  Mr.  T.  Wharton  Jones  wrote  the  article^ 
'*  Ear  and  Hearing,  Diseases  of.**  This  essay  was,  as  might  be 
expected  from  the  character  and  talents  of  its  author,  by  far  the 
best  resume  of  the  subject  which  had  appeared  in  British  print, — 
highly  learned,  and  at  the  same  time  in  many  respects  practicaL 
Mr.  Jones  commences  with  an  introduction  upon  the  analogy 
which  exists  between  the  anatomy  and  pathology  of  the  organs  of 
sight  and  hearing,  which  we  should  like  to  have  found  carried  on, 
as  we  believe  it  might  be,  through  the  entire  essay,  the  more  es- 
pecially as  from  the  author's  education  and  peculiar  acquirements 
it  is  probable  that  it  could  have  been  done  with  greater  advantage 
by  him  than  by  any  other  writer.  He  is  an  advocate  for  Eusti^ 
chian  catheteriem  and  the  use  of  vaporous  injections,  to  a  greater 


extent  than  yrill,  I  believe,  be  found  hereafter  necessary.  He  has, 
moreover,  introduced  into  this  article  the  minute  details  and 
daily  records  of  cases,  occupying  ten  pages,  which  is  rather  an 
unusual  proceeding  in  Cyclopaedia  writings,  and  more  in  accord- 
ance with  the  state  of  medical  literature  thirty  years  ago  than  at 
the  time  it  was  written.  It  would  partake  more  of  the  nature  of 
a  review  than  a  literary  analysis,  were  I  to  enter  upon  a  length- 
ened criticism  of  these  cases,  but  their  perusal  will,  I  think,  con* 
Yince  the  reader  of  their  inapplicability  to  the  place  where  they 
are  inserted.  One  case,  the  first  recorded  by  the  author,  is  worthy 
of  note.  A  female  complained  of  deafness  accompanied  by  tin- 
nitus, the  consequence  of  a  cold.  The  external  auditory  passages 
were  impacted  with  hardened  wax.  On  the  left  side  the  hearing 
distance  by  a  watch  was  but  two  inches.  Upon  the  wax  being 
removed  by  syringing,  the  hearing  distance  was  increased  to  '^  fif- 
teen feet  four  indiea^!  and  the  tinnitus  entirely  removed.  The 
membrana  tympani  is  said  to  have  been  **  opaque,  and  slightly 
yellow  ;**  but  the  report  does  not  state  whether  the  patient  could 
herself  inflate  the  cavity  of  the  drum.  A  solution  of  acetate  of 
lead  was  poured  into  the  auditory  passages  two  or  three  times  a 
day.  For  some  days  the  hearing  distance  varied;  a  catheter  wasf 
then  introduced,  and  the  air-douche  applied.  Upon  the  third  ap- 
plication the  air  penetrated  the  tympanum  freely,  and  the  hear- 
ing distance  was  then  increased  to  nineteen  feet  nine  inches ;  but 
the  report  does  not  say  what  it  was  previous  to  the  application 
of  the  douche.  There  are  few  persons  who  have  ever  experienced 
the  stuffing  and  annoyance  consequent  upon  **•  a  cold  in  the 
head,"  or  any  swelling  or  irritation  of  the  mucous  membrane  of 
the  fauces,  throat,  and  nose,  who  have  not  experienced  sensations 
and  variations  in  hearing  similar  to  those  recorded  in  the  case  re- 
lated in  the  Cyclopsedia  of  Surgery,  but  who  have  generally  cured 
themselves  by  blowing  the  nose,  sneezing,  or  coughing.  More- 
over, when  wax  has  been  a  long  time  impacted  in  the  auditory 
passage,  it  often  presses  the  tympanal  membrane  inwards,  and  the 
patient  does  not  quite  recover  the  hearing,  or  get  rid  of  the  tin* 
nitos,  for  some  days  after  the  removal  of  the  cerumen,  or  until  a 



forced  cxpimtion  presses  the  membrane  outwards  into  its  natmal 

During  the  last  fourteen  years  Mr.  Yearsley,  of  London,  has 
published  several  works  (and  issued  several  editions  of  each)  in 
connexion  with  diseases  of  the  ear.  The  first  of  these  was  Parti. 
of  **  Contributions  to  Aural  Surgery,"*  consisting  of  the  Proceed* 
ings  of  the  meetings  of  the  committee  for  managing  *<  The  Insti* 
tution  for  curing  Diseases  of  the  Ear,**  to  which  was  added  a 
Medical  Report,  and  also  the  detailed  account  of  cases.  The 
earliest  of  these  tracts  appeared  in  1839,  and  the  third,  which  is 
the  last  I  have  seen,  in  1841.  They  abound  in  copious  extracts 
from  various  authors,  and  in  particular  from  the  then  recently 
translated  work  of  Kramer.  In  these  publications  the  author 
chiefly  labours  to  impress  upon  the  profession  and  the  public  the 
necessity  of  Eustachian  catheterism  in  all  diseases  of  the  ear.  In 
1842  Mr.  Yearsley  published  '^  A  Treatise  on  the  Enlarged  Ton* 
ul  and  Elongated  Uvula,  in  connexion  with  Defects  of  Voice, 
Speech,  and  Hearing,  (ftc.,*"  of  which  several  editions  have  since 
appeared.  The  author  recommends  excision  of  the  tonsils  for  the 
cure  of  deafness,  and  we  believe  a  great  number  of  persons  have 
since  submitted  to  the  operation ;  with  what  degree  of  success  the 
profession  in  London  arc  the  best  judges.  Every  practical  phy* 
sician  and  surgeon  must  be  well  aware  that  enlarged  tonsils  do 
not  of  necessity  produce  deafness;  I  shall,  however*  leave  the 
further  discussion  of  that  subject  to  the  work  of  Mr.  Harvey,  to 
be  noticed  presently.  In  1847  there  appeared  by  the  same  au* 
thor,  **  Deafness  practically  illustrated,  being  an  Exposition  of 
Original  Views  as  to  the  Causes  and  Treatment  of  Diseases  of  the 
Ear.''  These  original  views  consisted  of  a  reprint,  with  scarcely 
an  alteration,  of  the  three  original  tracts  originally  published,  from 
1838  to  1841,  and  a  large  portion  of  the  book  upon  the  Throat 
just  referred  to,  to  which  were  added  chapters  upon  *'  Stomach 
Deafness ;''  the  Statistics  of  Deafness ;  on  the  best  means  of  com- 
pensating for  Incurable  Deafness ;  and  on  Ear  Trumpets.  The 
author's  description  of  stomach  deafness  is  as  follows: — *'  The  so- 
called  nervous  deafness,  hitherto  a  stumbling-block  to  contempo- 


raiy  writers,  is  nothing  else  than  an  injurious  influence  exerted 
on  the  ear  by  dyspeptic  ailments,  though  commonly  pronounced 
a  disease  depending  primarily  on  the  auditory  nerve  itself."  And 
again : — **  The  first  description  of  deafness  from  digestive  disorder 
is  that  in  which  the  disease  is  strictly  confined  to  the  stomach,  no 
perceptible  change  having  occurred  in  the  organ  of  hearing,  ex- 
cept functional  torpor  of  the  auditory  nerve.  This  is  best  seen  in 
acute  indigestion.**  Obstruction  of  the  biliary  secretion,  accumu- 
lation of  morbid  bile  in  the  gall  ducts,  and  chronic  dyspepsia,  are 
the  other  abdominal  derangements  supposed  by  the  author  to 
produce  deafness,  which  he  believes  to  be  caused  by  an  extension 
of  a  sub-inflammatory  condition  of  the  mucous  membrane  into 
the  throat,  and  thence  into  the  cavity  of  the  ear,  and  even  to  the 
external  meatus !  To  Mr.  Yearsley,  however,  is  due  the  credit 
of  having  first  drawn  the  attention  of  the  profession  to  the  very 
valuable  remedy  of  introducing  a  portion  of  moist  cotton  into  the 
external  meatus  in  oases  of  deafness  arising  from  perforation  of 
the  tympanal  membrane.  The  original  communication  upon  this 
subject  was  published  in  ''  The  Lancet**  for  July,  1848,  and  was 
afterwards  reprinted  as  a  tract  upon  '^  A  New  Mode  of  treating 
Deafness  when  attended  by  a  partial  or  entire  Loss  of  the  Mem-* 
brana  Tympani,  associated  or  not  with  Discharge  from  the  Ear.** 
This  question  will  be  again  considered  in  the  practical  portion  of 
this  work  devoted  to  Otorrhcea. 

Li  1844  Mr.  W.  Dufton,  of  Birmingham,  published  a  little 
work,  entitled  ^^  The  Nature  and  Treatment  of  Deafness  and  Dis- 
eases of  the  Ear,  and  of  the  Treatment  of  the  Deaf  and  Dumb.** 
And  in  1847  Dr.  J.  W.  Moses,  of  St.  Asaph,  wrote  a  short 
*^  Treatise  on  the  Human  Ear,  with  new  Views  of  the  Physiology 
of  the  Tjrmpanum.** 

Mr.  W.  Harvey,  of  London,  has  written  some  papers  on  Au- 
ral Sultry  in  the  periodicals,  and  published  a  Chart  of  Diseases 
of  the  Ear,  of  which  he  issued,  in  connexion  with  Mr.  Thomas 
Buchanan,  of  Hull, — to  whose  works  I  have  already  alluded  at 
page  25, — a  second  edition  in  1848,  entitled  *'  A  New  and  Im- 
[MToved  Synoptical  Table  of  the  Diseases  of  the  Human  Ear,  with 
tfieir  Symptoms,  Causes,  and  Treatment.**    Simplicity  of  nomen« 


36  HARTET. 

claturc  characterizes  most  modem  medical  writings,  at  least  in 
Great  Britain,  and  to  this  end  the  labours  of  Mr.  Farr,  in  his 
various  publications  upon  Vital  Statistics  have  tended  in  no  small 
degree.  One  can  therefore  scarcely  appreciate  the  advantage  de- 
rivable from  any  classification  abounding  in  terms  like  the  follow* 
lowing: — akoluthise,  dermatine,  anachrosis,  ptoeees,  kerinadids^ 
sunakolouthesis,  derringitis,  apoplanesis,  laburinthitis,  stereas, 
skleragosis,  &c.  &c.  In  1850  Mr.  Harvey  published  a  book 
''  On  Excision  of  the  Enlarged  Tonsil,  and  its  Consequences  in 
cases  of  Deafness,  with  Remarks  on  Diseases  of  the  Throat** 
In  this  most  useful  work  the  author  has  fairly  established  the 
fact  that  removal  of  the  tonsils  docs  not  cure  dea&ess,  and  thai,  in^ 
dependent  of  any  risk  in  the  operation  itself,  the  excision  of  these 
bodies  is  oflen  attended  with  subsequent  unpleasant  results  to  the 
patients.  Every  author  who  writes  on  any  subject  connected 
with  diseases  of  the  ear  thinks  it  necessary  to  conclude  his  work 
with  a  chapter  on  deaf-dumbness,  although  very  few  modem 
writers  have  added  anything  to  our  stock  of  knowledge  as  regards 
the  statistics,  medical  treatment,  moral  management,  or  pathology 
of  that  affection,  because  very  few  practitioners  have  any  expe- 
rience of  such  matters.  The  following  paragraph  upon  this  sub- 
ject, from  Mr.  Harvey's  work,  is  an  example : — '*  A  deaf-mule 
can  learn  to  read  and  specJe  perfet^y^  without  hearing  a  sin- 
gle tone ;  so  that  the  only  true  test  of  a  deaf-mute  is  his  being 
able  to  converse  with  a  stranger  as  well  toithout  the  aid  ofkU  ey$i 
as  any  person  who  hears  well  is  daily  in  the  habit  of  doing.** — 
page  104.  Now  in  the  English  and  American  schools,  and  most 
of  those  on  the  Continent,  all  attempts  to  make  the  deaf  and  dumb 
articulate  have  of  late  years  been  relinquished ;  and  how  the  deaf* 
mute  is  able  to  converse  with  a  stranger  without  the  aid  of  his 
eyes,  one  is  at  a  loss  to  discover.  Mr.  Harvey  promises  to  trans- 
late and  annotate  the  work  of  Lincke  referred  to  at  page  29,  and 
also  to  afford  us  a  book  on  certain  rheumatic  diseases  of  the  ear. 

Among  the  writings  bearing  on  this  subject  may  be  mentioned 
the  interesting  work  of  the  Rev.  Dr.  Kitto  on  *^  The  Lost  Senses — 
Series  I.  Deafness,**  published  in  1845,  in  which  the  feelings,  sen- 
sations, and  impressions  of  the  author,  himself  the  subject,  as  he 


states,  of  **  the  most  intense  deafness  to  which  any  living  creature 
can  be  subjected,**  are  graphically  and  feelingly  described. 

The  labours  and  investigations  of  Mr.  Toynbee  have  effected 
more  for  aural  pathology  than  those  of  all  his  predecessors  either 
in  England  or  on  the  Continent.  He  commenced  at  the  right 
end,  and  has  travelled  in  the  proper  direction.  He  has  brought 
t6  bear  upon  the  subject  the  true  principles  of  science,  and  with 
the  assistance  of  the  microscope, — the  aid  of  every  modem  artistic 
appliance  to  assist  him, — accustomed  to  habits  of  minute  dissec* 
tion,  patient  research,  and  careful  observation, — he  has  accumulated 
a  mass  of  facts  upon  the  morbid  anatomy  of  the  organs  of  hearing 
that  must  lay  the  foundation  for  a  more  rational  mode  of  treating 
the  diseases  of  those  parts  than  has  heretofore  been  resorted  to. 
Mr.  Toynbee  has  already  recorded  the  results  of  the  dissection  of 
the  ears  of  about  750  persons  sent  to  him  for  examination,  but 
of  which  number  not  more  than  sixty  or  seventy  were  from  per« 
sons  the  history  of  whose  deafness  was  known. 

Mr.  Toynbee  has  laboured  extensively,  and  with  effect,  to 
discover  and  describe  the  post-mortem  appearances  which  disease 
has  produced  in  the  organ  of  hearing ;  and  I  trust  he  will  long 
continue  to  prosecute,  with  the  same  avidity,  the  same  honesty  of 
purpose,  and  an  equal  amount  of  critical  acumen,  his  valuable  re- 
searches. Morbid  anatomy,  however,  is  one  thing — pathology 
another.  The  dead  subject  upon  the  dissecting-table  teaches  the 
student  not  disease,  but  the  results  of  disease.  It  avails  little  that 
the  hospital  pupil  should  have  pointed  out  to  him,  in  the  dead- 
room,  the  violence  which  sudden  accidents  may  have  caused,  or 
the  ravages  which  slow  disease  has  produced  in  the  various  organs 
or  textures  of  the  body ;  it  matters  not  to  what  extent  the  micro- 
scope may  exhibit  the  wide-spread  lesion,  or  chemical  tests  dis- 
close morbid  products,  unless  the  cases  have  been  observed  during 
life,- and  the  progress  of  disease  previously  noted  at  the  bedside. 
Therefore  it  is  that  the  School  of  Vienna, — where  a  dozen  bodies 
from  different  parts  of  the  Great  Hospital,  but  the  histories  of 
which  are  unknown,  are  sometimes  cut  up,  and  their  post-mortem 
appearances  displayed  in  the  lecture-room  on  a  morning, — may, 
under  the  able  teaching  of  Rokitansky,  Engel,  and  others,  teach 


morbid  anatomy,  (pathology  ao  called),  but  does  not  prodnoe 
many  practical  physicians. 

Mr.  Toynbee*8  researches  prove  the  pontioa  which  I  long  ago 
advanced,  and  which  from  year  to  year  I  have  been  in  the  habit» 
not  only  of  teaching  theoretically,  but  practically  demonstrating 
in  my  clinical  lectures, — that  the  great  majority  of  diseases  of  the 
ear  producing  deafness  have  their  origin  in  inflammations  of  one 
kind  or  another.  Every  day's  experience  confirms  me  in  this 
opinion ;  and  the  cases  which  I  now  publish  will,  I  think,  oorro- 
borate  that  view  of  the  subject.  Mr.  Toynbee  has  not  jret  pub- 
lished any  separate  work  upon  the  ear,  but  has  contributed  his 
observations  on  the  Anatomy,  Pathology,  and  Treatment  of  the 
Organs  of  Hearing  to  the  different  societies,  and  also  to  the 
periodicals,  of  London.  Among  the  latter  may  be  mentioned 
chiefly,  the  Philosophical  and  Medico-Chirurgical  Transactions, 
from  1843  until  the  present  date.  He  has  also  written  several 
valuable  papers  in  the  Medical  Times,  Lancet,  Provincial  Jour- 
nal, and  Edinburgh  Medical  Journal. 

Subsequent  to  Mr.  Yearsley's  recommendation,  a  fluid  called 
glycerine  was  recommended,  on  account  of  its  inevaporability,— > 
a  property  which  it  undoubtedly  possesses  more  than  most  other 
liquids, — as  the  only  proper  substance  with  which  to  moisten  the 
wool  or  cotton  introduced  into  the  meatus  in  cases  of  perforate 
membrana  tympani ;  and  from  being  employed  with  effect  in  one 
set  of  cases,  its  virtues  were  vaunted  as  a  cure  for  all,  and  during 
the  last  few  years  we  hear  this  medicine  extolled  in  the  public 
newspapers,  as  well  as  the  medical  periodicals,  as  a  panacea  for 
deafness  of  all  kinds,  and  arising  from  all  causes.  The  virtues  of 
glycerine  were  first  made  known  to  the  profession  through  Mr. 
T.  Wakley,  who  published  an  account  of  it  in  the  Lanoet  ia 
1849.  Since  then  glycerine  has  had  ^*  a  run,''  particularly  among 
the  members  of  the  profession  not  specially  engaged  in  the  tieat* 
ment  of  aural  diseases ;  and  we  may,  therefore,  well  imagine  in 
what  a  variety  of  cases,  arinng  from  the  most  opposite  causeti 
and  presenting  a  totally  different  set  of  symptoms,  this  remedy 
has  been  applied.  Cases  of  nervous  deafness  of  long  standing, 
thickening  and  opacity  of  the  membrana  tympani,  inflammation 

WAKLBY.  39 

and  mucous  engorgement  of  the  cavity  of  the  tympanum,  thick- 
ening of  the  cuticular  lining  of  the  meatus  resulting  from  otor- 
rhoea,  the  yarious  inflammatory  affections  of  the  ear,  as  well  as 
simple  impaction  of  the  meatus  with  cerumen,  are  constantly  for- 
warded to  me  by  practitioners  with  the  following  note : — ''  We 
have  applied  the  glycerine,  as  lately  recommended  for  the  cure  of 
dea/neaSf  for  some  weeks  past;  but  the  patient  not  having  expe- 
rienced reUef,  we  wish  to  have  your  opinion,"  &c.  When  the 
case  does  not  turn  out  favourably,  it  is  said  by  its  supporters  that 
the  remedial  agent  is  not  pure ;  and  when  its  purity  has  been 
tested  and  proved,  then  it  turns  out  that  the  remedy  was  inappli- 
cable to  that  particular  case.  Like  all  other  remedies  proposed 
for  deafness,  it  has  been  misapplied,  and  even  the  original  inten- 
tion of  its  inventor  lost  sight  of.  The  cases  to  which  it  is  said  to 
be  most  applicable  are  those  of  defective  cerumen,  dryness  of  the 
Auditory  passage,  thickening  of  the  membrana  tympani,  and  that 
peculiar  condition  of  the  epithelial  lining  of  the  external  conduit 
which  results  from  previous  otorrhoea.  Deficiency  of  cerumen  is 
but  a  symptom  contingent  upon  other  diseases ;  it  is  not  of  itself 
a  disease  of  the  ear  nor  a  cause  of  deafness ;  and  no  better  proof 
of  this  can  be  offered  than  that  instanced  by  a  case  of  defective 
hearing  caused  by  accumulation  of  hardened  wax.  The  patient 
is  totally  deaf,  and  labours  under  tinnitus  aurium  and  other 
symptoms  consequent  upon  such  mechanical  obstructions,  which 
are  well  kno¥m  to  every  practitioner.  The  application  of  a  jet 
of  warm  water,  properly  directed,  removes  the  hardened  wax, 
when  the  bearing  is  instantaneously  restored,  nay,  often  consider- 
ably exalted.  In  a  few  hours  the  meatus  becomes  perfectly  dry. 
Why  then  is  it  that  the  hearing  remains  perfect,  although  the  ce- 
rumen has  been  completely  washed  away  ?  Again,  as  to  dryness 
and  paleness  of  the  meatus,  it  should  be  remembered  that  such  is, 
with  the  exception  of  the  part  coated  by  cerumen,  its  natural 
condition.  As  regards  thickening  and  opacity  of  the  tympanal 
membrane,  if  glycerine  can  remove  such,  either  by  maceration, 
any  caustic  property  which  it  may  possess,  or  by  inducing  ab- 
sorption, then  indeed  will  it  be  found  a  great  boon.  In  cases  of 
thickening  of  the  Uning  membrane  of  the  meatus,  and  a  dry, 


scaly  condition  of  the  epithelium,  npon  the  drying  up  of  a  muco- 
purulent discharge,  it  ia  of  importance  to  restore  these  parts  to  a 
healthy  condition  by  remedial  agents,  of  which  glycerine  is  not 
the  best  nor  the  only  one.  There  are,  however,  cases  in  which 
benefit  will  be  derived  from  preserving  the  meatus  and  external 
layer  of  the  membrana  tympani  moist.  The  effect  of  such  mois- 
ture is  well  known,  not  only  to  aural  surgeons,  but  to  patient! 
themselves,  who  arc  in  the  habit  of  applying  a  little  oil  or  even 
water  upon  the  point  of  the  finger  to  the  external  meatus  when- 
ever they  find  their  hearing  particularly  defective;  and  in  such 
cases  tiiis  remedy,  from  its  remarkable  property  of  remaining 
fluid,  when  most  other  liquids  evaporate,  will  be  found  useful 
Such  cases,  however,  arc  comparatively  rare. 

The  substance  denominated  glycerine  was  discovered  by 
Scheele,  and  was  afterwards  investigated  by  Chevreul.  It  is  an 
almost  inodorous,  syrupy  fluid,  which  gives  a  peculiar  smoothness 
to  the  part  on  which  it  is  rubbed,  and  is  obtained  in  the  making  of 
litharge  plaster,  by  washing  that  substance,  and  passing  sulphu- 
retted hydrogen  gas  through  the  washings  to  remove  the  lead, — 
afterwards  filtering  and  evaporating.  It  is  soluble  in  water  and 
alcohol ;  does  not  dry  or  evaporate  at  the  ordinary  temperatuiei 
but  if  boiled,  it  partly  distils  and  partly  decomposes,  acroleine 
being  among  its  products, — and  it  is  not  liable  to  ferment.  It  is 
found  in  combination  with  most  oils,  except  that  obtained  from 
the  liver  of  the  cod,  now  in  such  extensive  use,  which  Winder 
has  ascertained  does  not  contain  it.  Time,  and  the  experience 
of  the  profession,  which  test  all  such  remedies,  no  matter  how 
vaunted  or  how  popular,  will,  no  doubt,  develop  the  therapeu* 
tical  effects  of  this  substance  in  diseases  of  the  ear,  if  such  it  pos-> 
sesses,  beyond  those  which  I  have  already  stated.  Its  powers  are 
already  beginning  to  be  questioned ; — a  book  has,  however,  been 
written  on  the  subject, — the  last  in  connexion  with  diseases  of 
the  ear  which  has  appeared  in  Great  Britain, — and  in  accordance 
with  the  principles  of  this  chapter  it  must  be  referred  to. 

In  1851  there  appeared  '*  Clinical  Reports  on  the  Use  of  Gly- 
cerine in  the  Treatment  of  certain  Forms  of  Deafiiess,  by  T. 
Wakley,  F.  R.  C.  S.    Edited  by  W.  Tindal  Robertson."    Any 


proposition  to  relieve  so  serious  and  so  widely-spread  an  infirmity 
as  dea&ess,  emanating  from  a  legalized  practitioner,  should  be 
hailed  by  the  profession  as  a  benefit  conferred  upon  science  and 
humanity ;  but  at  the  same  time  it  behoves  the  propounders  of 
such  cures  to  show  that  their  cases  are  well  worthy  of  credence, 
and  that  their  descriptions  of  disease,  details  of  symptoms,  diag- 
nosis, and  prognosis,  are  in  accordance  with  the  present  state  of 
medical  science  bearing  upon  such  affections.  Now,  I  do  not 
think  this  work  is  in  that  position.  For  the  application  of  gly- 
cerine the  author  recommends  an  instrument  resembling  a  porte- 
crayon,  for  holding  a  piece  of  cotton  saturated  with  the  new 
remedy.  The  external  meatus  being  washed  out  with  tepid 
water,  and  thoroughly  dried,  which  appears  to  be  a  necessary 
preliminary,  we  are  gravely  informed  that  the  cotton  '*  should  be 
80  fixed  that  in  moving  the  instrument  to  and  fro  in  the  external 
meatus,  the  free  passage  of  air  should  be  provided  for,  otherwise 
an  imperforate  tympanum  might  be  ruptured" ! !  The  book  con- 
tains the  record  of  twenty-eight  cases,  in  the  majority  of  which 
the  streets,  but  not  the  numbers,  in  which  the  patients  lived,  are 
given.  The  hearing  distance  before  the  application  of  the  re- 
medy is  not  stated,  although  the  author  has,  he  states,  invented  an 
instrument,  which  he  styles  a  Sonometer,  for  the  purpose  of  mea- 
suring the  hearing  distance,  and  which,  he  says,  ^'  has  proved  of 
the  greatest  value  in  practice,**  and  *'  has  done  service  to  the  pro- 
fession." But  what  that  value,  and  what  that  service  is,  beyond 
what  may  be  acquired  by  an  ordinary  loud-ticking  watch,  is  not 
recorded.^  In  reading  over  these  cases,  when  we  find  such  state- 
ments as  the  following,  we  are  inclined  to  think  that  their  re- 
porter— we  suppose  some  pupil  of  Mr.  Wakley's — was  not  very 
conversant  with  either  the  normal  or  pathological  appearances  of 
the  human  ear: — "  The  tympanum  of  each  ear  was  sound.** — 
•*  The  tympanum  of  each  ear  was  perfect.** — "  Care  having  been 
taken  to  apply  it  to  the  tympanum.**  We  suppose  the  reporter 
alluded  to  the  membrana  tympani.    Again  we  read :  *'  When  the 

*  I  Mw  a  timiUur  instniment  uaed  by  Dr.  Schmalz  in  Dreaden  in  1840.  He  claimed 
the  inveoUoo  of  it,  and  has  described  it  in  his  various  writings. 


ears  are  under  the  influence  of  glycerine.** — ^*  The  meatus  of  each 
ear  is  exceedingly  hard.** — **  Of  a  very  pale  colour.** — **  The  aural 
passage  and  tympanum  [jjuere  middle  ear]  exhibited  a  white,  po- 
lished appearance,**  &c.  Among  the  cases  related  is  that  of  a  boy, 
deaf  and  dumb,  in  which  the  author  says: — '<  The  ears  are  Tery 
small.**  We  then  hear  that  "  the  ears  were  well  mOurated  with 
glycenne,**  and  the  hearing  distance  tested,  when,  marvelloufl  lo 
relate,  the  boy  seemed  ^'  to  signify  with  his  fingers  the  number  of 
times  he  was  called  by  his  father.**  **  It  is  evident,**  says  the  au- 
thor, in  concluding  the  report  of  this  case,  **  that  he  received  a 
certain  amount  of  benefit  firom  the  glycerine.**  Here  now  ia  a  &ir 
case: — E.  M.,  Dean-street,  London,  a  deaf-mute,  who  ia  said  to 
have  derived  benefit  from  this  remedy.  Let  the  boy  be  produced 
to  the  profession,  and  to  the  instructors  of  the  deaf  and  dumb, 
and  let  them  decide  upon  the  amount  of  benefit  derived  from  this 
or  any  other  remedial  agent  in  curing  a  case  of  true  muteiam. 
These  cases,  however,  in  which  even  '*  a  certain  amount  of  bene- 
fit** is  said  to  have  been  derived  from  treatment  of  any  kind  by 
an  unhappy  deaf-mute,  have  their  efiect  upon  the  public  mind,  as 
was  instanced  some  years  ago  in  the  TumbuU  cures  related  in 
Chambers's  Journal,  to  be  referred  to  presently. 

In  a  second  section  of  this  book,  consisting  of  a  clinical  lec- 
ture on  the  use  of  glycerine,  illustrated  by  eleven  cases,  in  which 
the  remedy  is  most  advisable,  we  find  that  four  were  instances  of 
simple  impaction  of  wax,  which  might  have  been  removed  in  a 
few  minutes  by  some  warm  water  and  a  syringe.  In  the  fiiit 
portion  of  the  work,  dry  cotton  is  the  substance  recommended  for 
the  application  of  the  glycerine ;  in  the  latter  section,  howeverp 
at  p.  64,  sheep's  wool  is  that  deemed  most  advisable  by  the  author. 
I  have  already  alluded  at  p.  3  of  this  chapter  to  the  old  Irish  re- 
medy, which  partakes  more  of  the  nature  of  a  superstition  than  a 
therapeutic  agent  of  a  cure  for  deafness,  in  a  bit  of  wool,  taken  at 
a  particular  time,  and  under  particular  circumstances,  from  the 
left  fore-leg  of  a  six  years  old  black  ram.  In  the  metropolis  of 
the  world,  during  the  middle  of  the  nineteenth  century,  with  sci- 
ence, philosophy,  and  common  sense  influencing  the  actions  of 
mankind  to  the  extent  which  at  present  prevails,  one  did  not  ex- 


pect  to  find  the  aurgeon  of  a  London  hospital  recommending  as  a 
portion  of  the  new  cure  for  deafness,  '*  the  finest  curled  wool  on 
the  sheep's  heady  carefully  cut  with  scissors,  and  washed  in  hot 
water,"  and  adding,  '^  the  best  wool  is  that  procured  from  a  small 
German  sheep  f  age  unspecified. 

I  have  dwelt  thus  long  upon  the  present  popular  cure  for 
deafiiess,  and  endeavoured  to  expose  its  fallacy,  in  the  hope  that 
the  eyes  of  the  profession  may  be  opened  to  the  ine£Scacy  of  such 
modes  of  treatment,  and  that  our  continental  neighbours  may  not 
have  an  opportunity  again  of  writing  such  critical  reviews  of  Bri* 
tish  authors  as  those  which  formed  an  introduction  to  Dr.  Kra* 
mer^s  book. 

Well-educated  surgeons  and  honest  men  have  at  last  come 
forward  to  rescue  this  branch  of  the  healing  art  from  the  hands  of 
quacks  and  charlatans ;  and  the  names  of  those  respectable  gen* 
ll«men  who  at  present  practice  aural  surgery  in  Great  Britain  are 
a  sufficient  guarantee  that  the  empiric  and  the  nostrum-monger 
will  soon  be  driven  from  the  field.  Yet  that  some  of  those  latter 
still  drive  a  thriving  trade  may  be  learned  from  the  puffs  and 
praises  bestowed  upon  them  in  the  literary  periodicals  of  the  day. 
In  one  of  these,  which,  from  our  own  knowledge  of  the  honour 
and  integrity  of  its  editors,  as  well  as  its  hitherto  stem  and  un- 
compromising .stand  against  quackery  of  every  description,  and 
its  high  reputation  for  honesty  of  purpose  and  substantial  literary 
merit,  we  really  expected  better  things,  it  was  some  time  ago  not 
only  asserted,  but  endeavoured  to  be  proved,  that  by  dropping 
**  an  alkaloid**  into  the  external  meatus,  or  rubbing  the  surface  of 
the  membrana  tympani  with  it,  persons  bom  deaf  and  dumb  have 
been  almost  instantaneously  cured  I  nay,  not  only  is  hearing  re- 
flared  on  the  moment,  but  the  miracle  (for  miracle  it  certainly  is, 
if  true)  extends  to  the  organs  of  speech  also,  as  in  one  caae,  and 
that  too  given  on  the  faith  of  a  medical  man,  and  conveyed  in  a 
letter  to  the  operator,  he  says,  that  '*  after  repefUed  examinations 
of  many  of  the  objects  under  your  care,  previously  to  anything 
being  done,  I  satisfied  myself  that  they  were  both  deaf  and  dumb. 
I  have  witnessed  the  application  of  your  remedy  to  the  ears,  and 
bear  testimony  to  them  having  in  my  presence  obtained  the  sense 


of  hearing.**  But — miracle  upon  miracle — the  fiusulty  of  speech 
to  one  who  had  never  heard  the  sweet  sounds  of  a  human  yoiee* 
follows  almost  as  matter  of  course ;  for,  adds  the  narrator,  <*  and 
by  my  own  tuition,  in  a  few  miniUea  a/tenoards  acquired  thepawtr 
of  speech  F    I  wonder  was  it  broad  Scotch  they  spoke  I 

The  history  of  this  affair  is  as  follows: — In  1837  there  ap- 
peared in  London  **  A  Treatise  on  Painful  and  Nervous  Affections, 
and  on  a  new  mode  of  Treatment  for  Diseases  of  the  Eye  and  Ear, 
by  A.  Tumbull,  M.  D.'*  The  portion  devoted  to  the  considenh 
tion  of  affections  of  the  latter  organ  is  comprised  in  six  page8» 
and  the  treatment  consisted  of  the  application  of  the  alkaloid  va- 
ratria  to  the  external  meatus  and  the  parts  joining  the  auride. 
'^  Feeling  satisfied,**  says  the  author,  *'  that  I  had  in  my  possession 
means  decidedly  effective  in  promoting  absorption  through  the 
medium  of  the  nerves,  and  knowing  that  deafness  often  arose 
from  the  Eustachian  tube  being  obstructed  by  enlarged  tonsil 
glands,  I  applied  vcratria  externally  over  these  glands,  and  found 
it  frequently  succeed  in  removing  their  enlargement  and  restoring 
the  hearing.**  The  "  electro-stimulation,**  as  the  author  terms  it, 
having  been  found  so  efficacious  in  removing  deafness,  such  as 
has  been  described  in  the  foregoing  quotation,  he  was  induced  to 
extend  its  benefits  to  the  deaf  and  dumb,  and  shortly  afterwards 
it  was  announced  that  Dr.  Tumbull  had  cured  several  deaf-mutes; 
and  advertisements  appeared  in  the  newspapers  for  persons  to  in- 
struct those  patients  cured  by  such  means.  The  possessor  of  this 
valuable  discovery  next  proceeded  to  Scotland,  to  operate  upon 
the  deaf  and  dumb  portion  of  the  inhabitants  of  that  country,  but 
his  cures  were  questioned,  and  his  statements  rather  severely 
criticised,  in  that  valuable  publication,  Chamber's  Journal,  for 
28th  September,  1839.  By  some  means,  however,  he  afterwards 
proved  his  case  to  the  satisfaction  of  the  Editors,  and  then,  in 
their  publication  for  8th  January,  1842,  No.  519,  they  acknow- 
ledged, in  an  article  headed  ''  Cures  for  Deafness,"  the  in- 
justice of  their  previous  attack,  and  were  equally  loud  in  praise 
of  the  cures  said  to  have  been  achieved.  Several  of  these  cures 
were  said  to  have  been  effected  upon  children  either  in  the  Deaf 
and  Dumb  Institutions  of  Scotland,  or  known  to  some  of  the 

Chambers's  journal.  45 

principals  of  these  establishments ;  and  consequently  the  late  Mr. 
Robert  Kinniburgh,  a  gentleman  of  great  truth  and  vast  expe- 
rience in  the  management  of  the  deaf  and  dumb,  addressed  a 
letter  to  the  Editors,  proving  distinctly  in  each  individual  case  re- 
lated that  no  cure  was  effected.  This  letter,  of  which  I  possess  a 
copy,  was  published  upon  the  28th  February,  1842,  but  it  was 
only  privately  circulated. 

It  is  always  a  matter  of  difficulty  to  argue  on  a  medical  sub- 
ject with  a  non-professional  person,  for  it  is  quite  impossible  for 
a  man  uninstructed  in  anatomy,  physiology,  medicine,  and  sur- 
gery, to  be  convinced  of  his  error, — to  form  an  opinion  of  the 
merits  of  a  cure,  or  the  causes  of  a  failure.  Such  discussions  with 
non-medical  persons  should  be  avoided  as  much  as  possible,  they 
tend  to  no  good,  and  were  it  not  our  conviction  that  Mr.  Cham- 
bers, for  whom  we  entertain  the  highest  respect,  had  been  made 
ike  dupe  of  Dr.  TumbuU,  we  would  not  thus  have  alluded  to  the 
snbject  here.  How  few  students,  after  two,  or  even  three  years* 
study  in  the  preparatory  and  elementary  courses,  would  be  ca- 
pable of  estimating  the  value  of  any  medical  production  put  into 
their  hands  I  and  yet,  *'  in  order  to  ascertain  in  what  respects 
Dr.  Tumbull's  practice  differed  from  that  which  is  general  in  the 
profession,**  we  were  gravely  informed  by  the  Editors  of  the  Edin- 
burgh Journal,  that  they  ^*  studied  the  most  recent  and  approved 
works  on  aural  surgery.**  Had  the  writer  known  anything  of  the 
structure  of  the  parts  he  attempted  to  describe,  he  would  have  been 
better  informed  than  to  publish  an  account  of  an  analogy  between 
the  ceruminous  glands  in  the  external  meatus,  and  the  mammary 
gland  in  the  female ;  for  in  the  article  to  which  I  allude  he  says : 
**  Finding  cured  persons  relapse  in  consequence  of  the  defect  of 
wax,  Dr.  Tumbull  was  prompted  to  use  his  ingenuity  in  endea- 
vouring to  discover  a  means  of  sustaining  that  secretion.  He 
reflected  that  the  application  of  the  mouth  of  the  child  to  its  mo- 
ther*s  breast,  by  removing  the  pressure  of  the  atmosphere,  causes 
the  milk  immediately  to  flow,  and  he  conceived  that  a  similar  re- 
sult might  follow  with  respect  to  the  wax  of  the  ears,  if  he  could 
hj  any  means  remove  the  pressure  of  the  atmosphere  from  the 
external  parte.    For  this  purpose,  he  at  first  used  a  syringe  with 

46  chambbbs'b  JoumvAL. 

an  Indian-rubber  mouth  exactly  fitted  to  the  aperture  of  the 
ear,**  &c.  Now  the  veriest  tyro  in  medicine  knows  that  it  does 
not  depend  on  any  atmospheric  pressure,  but  is  owing  to  a  mor^ 
bid  action  in  these  follicles  themselves  that  the  ear  wax  is  not 
secreted.  But  yet  we  read — *'  the  plan  was  successful  ;**  and  the 
reason  assigned  is,  because  **  the  blood-osifalf  resumed  a  free  cir- 
culation, and  the  flow  of  wax  recommenced." 

Again,  we  learn  that  **  the  clearing  of  the  Eustachian  tube,  for 
which  no  means  formerly  existed  but  the  application  of  medicinie 
to  the  bowels,  or  the  dangeroue  use  of  a  catheter,  was  affected  by 
Dr.  TurnbuU  by  the  same  simple  means."  Well  might  the  friends 
and  admirers  of  the  Doctor  employ  the  term  dangerous^  for  the 
only  record  of  any  accident  or  ill-effect  having  arisen  from  the 
employment  of  this  exceedingly  simple  and  harmless  operalioD 
occurred  to  Dr.  TurnbuU  himself,  two  of  whose  patients,  in  the 
year  1839,  fell  victims  to  the  operation  of  catheterism  of  the  Eus* 
tachian  tube,  and  on  both  of  whom  coroner's  inquests  were  held. 
One  of  these,  it  appeared  in  evidence,  was,  almost  immediately 
after  the  operation,  attacked  with  emphysema  of  the  throat  and 
inflammation  of  the  brain,  of  which  he  died  in  a  week ;  and  the 
other,  a  lad  named  Joseph  Hall,  aged  18,  and  in  perfect  health, 
'*  fell  back  in  the  chair  apparently  lifeless,  and  never  spoke  after- 
wards."— (Lancet,  July  6,  1839.)  In  the  first  of  these  cases  it 
appears  most  likely  that  the  emphysema  was  caused  by  the  instru- 
ment rupturing  and  tearing  the  mucous  membrane ;  and  in  the 
second,  in  all  probability,  the  death  was  caused  by  the  shock  or 
concussion  given  to  the  base  of  the  skull  by  the  volume  of  com- 
pressed air, — ^for  where  the  mouth  of  the  catheter  was  we  know 
not  After  this  it  seems  the  Doctor  changed  his  hand,  and  find- 
ing that  it  was  rather  a  "  dangerous**  experiment  to  '*  blow  up" 
his  patients,  he  determined  to  euck  them  as  much  as  possible; 
and,  in  order  to  effect  this,  Mr.  Chambers  informs  us,  that  by 
means  of  an  air-pump,  in  connexion  with  a  small  glass  tube, 
''  introduced  into  the  mouth  of  the  patient,  and  applied  to  the 
orifice  of  the  Eustachian  passage,**  and  consequently  behind  and 
above  the  soft  palate  1  communication  is  opened  between  the  pre- 
viously rarified  air  in  the  receiver  and  the  orifice,  from  which  a 


discharge  of  mucus  is  «oon  made  into  the  tube,  which  is  then 

With  one  word  more  let  us  dismiss  this  subject  of  Dr.  Turn- 
bull  and  his  reviewers ; — a  word  worthy  of  consideration  to  those 
who  may  be  induced  by  articles  such  as  that  to  which  I  have  al- 
luded to  submit  their  deaf-mute  friends  or  relatives  to  useless 
pain  and  profitless  experiment;  and  many  an  anxious  parent — 
some  from  this  country — upon  the  faith  of  the  report  then  pro- 
pagated, and  relying  on  the  truth  of  these  cures,  visited  the 
inventor  of  the  alkaloid,  and  several  spent  considerable  sums  of 
money  in  the  vain  hope  of  even  once  hearing  their  children  arti- 
culate. That  word  is  this — and  it  is  the  more  suitable  on  account 
of  the  sanctimonious  air  assumed  in  the  application  of  the  means 
employed, — Were  the  miraculous  cures  of  the  Saviour,  who 
dghed  over  the  case  of  the  deaf-mute,  performed  on  cases  or  in 
diseases  that  art,  either  then  or  now,  could  have  remedied? — 
could  remedial  agents,  or  man's  interference,  have  raised  the 
dead — thrown  instantaneously  the  vigour  of  youth,  and  the  health 
and  strength  of  manhood,  into  the  limbs  of  the  cripple — given 
power  to  the  paralytic — steadiness  to  the  palsied — and  calmness 
to  the  possessed ;  or  have  cooled  the  fevered — given,  by  a  word, 
light  to  the  blind,  speech  to  the  dumb,  and  hearing  to  the  deaf? 
— ^If,  without  the  special  interference  of  Providence,  tliese  indi- 
viduals could  have  been  cured,  then  their  cases  were  not  miracles; 
but  if  without  the  pale  of  art,  or  beyond  the  power  of  human 
means,  then  were  they  miracles,  and  cannot  now  be  performed 
but  by  similar  means.  That,  however,  the  age  of  miracles  was  at 
hand,  Mr.  Chambers  appeared  to  have  some  idea,  for,  no  doubt, 
aware  of  the  instantaneous  restoration  of  speech  and  hearing  to 
the  deaf-mute  being  one  of  the  miracles  assigned  to  Christ,  he 
concludes  by  saying: — *<*  Every  thing  but  trodden  out  of  exist- 
ence,' is,  in  one  word,  the  fate  of  the  individual  who  has  been  the 
first  Merely  Human  being  to  cause  the  deaf  to  hear.*" 

Having  many  years  ago  discussed  this  subject,^  it  is  unneces- 

•  "  ContriboUons  to  Aaral  Surgery,  Part  II.,  The  Early  History  of  Aural  Sui^ry, 
with  a  Nosological  Chart  of  Diseasce  of  the  Ear.** — Dubliu  Joomal  of  Medical  Science  for 
July,  lSi4. 


sary  to  expatiate  upon  it  further.  The  public  should,  however, 
be  guarded  from  these  impostures,  which  are  from  time  to  time 
offered  for  the  cure  of  incurable  diseases;  among  these,  deaf-dumb- 
ness— some  cases  of  which  are  now,  I  understand,  undergoing  a 
series  of  mesmeric  experiments — is  one  of  the  most  fruitful. 

The  various  Cyclopaedias  of  Medicine  published  in  Great  Bri- 
tain contain  articles  upon  aural  diseases ;  among  these.  Dr.  Cop- 
land's ''  Dictionary  of  Practical  Medicine,**  Article,  Ear  and 
Hearing,  Parts  III.  and  IV.,  may  be  specially  noticed,  as  embo- 
dying a  compilation  of  the  opinions  of  the  best  authors  on  the 
subject.  T.  Chevalier  published  in  I^ndon  a  treatise  **  On  the 
Cure  of  Polypi  in  the  Meatus  Auditorius  Extemus  with  Sulphate 
of  Zinc,**  in  1843;  I  have  not,  however,  seen  the  book. 

With  respect  to  the  Irish  manuscripts  to  which  reference  was 
made  at  p.  8,  it  could  not  be  expected  that  works  of  that  early 
date  would  afford  much  information  on  an  art  which  has  within 
the  last  few  years  only  been  raised  to  the  level  of  surgical  and 
medical  science.  Several  of  these  manuscripts  contain  curious 
receipts  for  deafness,  consisting  chiefly  of  the  juice  of  herbs,  pre- 
pared according  to  a  particular  formula,  and  dropped  into  the 
external  meatus ;  among  which  the  roots  and  flowers  of  cowslip 
and  the  red  mesmir  mixed  with  honey,  occur  frequently ;  saffron 
and  burdock  boiled  on  vinegar,  and  roasted  figs,  were  much  em- 
ployed ;  and  eel  oil  was  then,  as  it  is  still,  a  favourite  popular 
receipt  for  deafness.  In  the  Book  of  the  O'Lees  there  is  a  chap- 
ter devoted  to  the  consideration  of  diseases  of  the  ear,  but^  like 
most  of  the  other  writings  of  that  period,  it  consists  chiefly  of  an 
enumeration  of  the  '*  cures**  in  most  general  use  for  deafness. 

I  am  not  acquainted  with  any  native  American  work  on 
aural  surgery ;  and  the  medical  periodicals  of  that  country  have 
recorded  but  few  cases  of  interest  in  connexion  therewith.  The 
only  book  which  I  know  is  that  of  Saissy,  <'  An  Eissay  on  the 
Diseases  of  the  Internal  Ear,  translated  from  the  French,  by  Na- 
than R.  Smith.**  Baltimore,  1829.  The  first  volume  of  Baron 
Larrey's  ''  Clinique  Chirurgicale^  containing  a  chapter  on  Le- 
sions of  the  Ear,  was  translated  by  Dr.  Rivinus,  of  Philadelphia, 
in  1832. 


Edinburgh  has  not  contributed  much  towards  aural  surgery. 
I  know  of  but  one  special  work  on  diseases  of  the  ear  which  has 
issued  from  the  Press  of  that  ancient  and  celebrated  School  of 
Medicine  since  the  time  of  Degravers,  viz.  **  Treatise  on  the  Ac- 
cessary Organs  of  Hearing,  comprising  the  Special  Pathology  and 
Treatment  of  their  Diseases,  by  James  Mercer,  M.D.,**  which  was 
written,  I  understand,  as  a  probationary  essay  for  the  Fellowship 
of  the  College  of  Surgeons  in  1840.  In  the  Monthly  Journal  for 
March,  1848,  will  be  found  a  very  useful  paper  on  the  pathologi- 
cal sequences  of  acute  inflammation  of  the  fibro-mucous  structure 
of  the  cavity  of  the  tympanum,  by  the  same  author. 

In  the  Monthly  Journal  of  Medical  Science  for  1845  and  1846, 
Dr.  A.  Warden,  "  Aurist  in  Ordinary  to  the  Queen,"  published 
papers  on  the  Inspection  of  the  Meatus  Auditorius  Externus. 
This  gentleman  fixed  to  the  ordinary  tubular  speculum  a  prism 
for  the  purpose  of  polarizing  light,  — a  totally  useless  addition. 
In  1847  he  promised  a  work  on  the  subject,  of  which  the  follow- 
ing is  the  advertisement,  as  it  appeared  in  one  of  the  Scotch 
newspapers : — *'  In  the  Press,  and  shortly  will  be  published,  the 
Nature  and  Treatment  of  Diseases  of  the  Ear,  as  more  fully  re- 
vealed by  the  Prismatic  Auriscope ;  with  fifty  coloured  Delinea- 
tions of  Natural  and  Diseased  Conditions. — *  With  the  Prism  in 
our  hand  we  may  now  go  forward  as  with  a  torch  powerful 
enough  to  dispel  all  obscurity,  and  to  enable  and  entitle  us  to 
plant  the  union-jack  of  the  profession  on  the  whole  domain  in  the 
usual  form  of  maps  and  delineations  of  disease.' — Preface!^  Nei- 
ther work  nor  preface  ever  appeared,  and  criticism  of  the  dead 
would  now  be  ungenerous. 

While  these  pages  are  passing  through  the  press,  Mr.  Harvey, 
of  London,  whose  writings  have  been  already  alluded  to  at  p.  35, 
lias  issued  another  work,  entitled,  <*  Rheumatism,  Gout,  and  Neu- 
ralgia, as  affecting  the  Head  and  Ear;  with  Remarks  on  some 
forms  of  Headach  in  connexion  with  Deafness."  In  it  the  author 
appears  to  be  under  the  impression  that  he  is  entitled  to  originality 
for  his  views, — my  answer  to  that  will  be  found  at  pp.  225  and  267. 

The  literature  relating  to  deaf-dumbness  will  be  considered  in 
the  section  bearing  on  that  subject. 



What  is  the  legitimate  aural  practitioner  in  the  present  day, 
and  how  far  does  his  art  extend  over  disease  ?  A  practitioner  in 
aural  surgery,  or,  if  it  pleases  the  public  to  call  him,  an  Aurist,  in 
our  day  must,  or  at  least  he  ought  to  bo,  a  well-educated  surgeon 
or  physician,  who  applies  the  recognised  principles  of  medicine 
and  surgery  to  diseases  of  the  organs  of  hearing,  in  the  same 
manner  as  the  modern  ophthalmic  surgeon  does  to  diseases  of  the 
eye.  We  daily  hear  and  read,  and  it  has  been  reiterated  from 
mouth  to  mouth,  and  copied  from  work  to  work,  that  the  treat- 
ment of  such  affections  is  an  opprobrium  to  the  healing  art,  "  in 
surditate  quidnam  eat  male^  and  that  deafness  is  without  the  pale 
of  human  knowledge.  Now  notwithstanding  the  injudicious  treat- 
ment by  quacks  and  nostrum-mongers,  the  neglect  of  patients, 
and — as  in  many  instances  we  know  it  is — the  total  abandonment 
of  all  treatment  by  the  general  practitioner,  still,  were  the  statis- 
tics of  all  diseases  carefully  collected,  it  would  be  found  that  there 
were  among  them  as  many  curable  cases  of  affections  of  the  ear 
as  there  are  among  the  severer  maladies  of  the  eye,  or  among  dis- 
eases of  the  chest,  the  brain,  the  liver,  or  any  other  organ.  Up  to 
a  very  recent  period,  from  well-educated  medical  men  in  this  coun- 
try either  considering  it  beneath  their  station  or  acquirements  to 
treat  so  insignificant  an  organ  specially,  or  not  finding  in  the 
direct  cultivation  of  aural  surgery  a  sufficient  remuneration  for 
their  time  and  talents,  this  branch  of  the  healing  art  remained 
in  the  state  in  which  ophthalmic  surgery  was  half  a  century  ago. 
All  this — added  to  the  smaller  share  of  sympathy  afforded  to  the 
deaf  than  the  blind ;  to  impairment  of  hearing  interfering  less 
with  man's  means  of  subsistence,  and  also  to  the  great  difficulty 
of  cither  minutely  examining  during  life,  or  of  investigating  after 
death,  the  morbid  changes  which  occur  in  the  middle  and  intei^ 
nal  car — serves  to  account  for  aural  surgery  and  pathology  not 
having  kept  pace  with  the  other  rapid  improvements  in  medical 
science.  Yet  the  well-instructed  aurist  of  our  time  possesses  a 
knowledge  and  a  power  which  is  not  general  among  the  profes- 
sion—  of  making  an  accurate  diagnosisy  which,  when  given  with 
honesty,  will  frequently  save  the  patient  much  anxiety,  unneces- 
sary suffering,  and  loss  of  time  and  money. 




Plan  of  the  Work. — Records  of  Cases. — Means  of  forming  a  Diagnosis,  and  mode  of 

Examination Physical  Signs. — InstrumeDts  and  Remedies. — The  Auditory  Canal 

and  Membrana  Tympani. — Lamps,  the  various  forms  of. — The  Speculum. — Eusta- 
chian Catheterism. — The  Stethoscope.— Syringing The  Hearing  Distance. — ^The 

Throat. — The  Yoioe.— Tinnitus. — Subjective  Symptoms. — Depletion. — Leeches. — 
Counter-Irritation. — Galvanism  and  Electricity. — Mercury,  &c. 

HAVING  in  the  preceding  chapter  offered  some  remarks 
upon  the  subject  of  Aural  Surgery  generally,  and  given  a 
short  outline  of  the  history  of  the  art,  I  will  now  explain  the 
plan  which  I  have  adopted  in  the  following  chapters.  At  the 
commencement  of  each  I  have  given  a  brief  anatomical  descrip- 
tion of  the  parts  concerned  in  the  affections  under  consideration, 
and  a  concise  account  of  their  most  remarkable  malformations  and 
congenital  diseases ;  afterwards,  the  etiology  and  treatment  of 
those  diseases  with  which  I  am  myself  most  familiar  are  described. 
I  have  followed  that  division  into  the  diseases  of  the  external, 
middle,  and  internal  ear,  because  it  seems  to  facilitate  description, 
as  well  as  to  make  the  most  lasting  impression  on  the  mind  of  the 
student.  The  work  concludes  with  a  section  on  deaf-dumbness, 
which  contains  the  result  of  the  inquiry  set  on  foot  under  the 
Irish  Census  Commission  for  1851,  and  which  I  have  compressed 
from  the  official  Report  upon  that  subject* 

From  1843  to  the  present  time  I  have  published  several  essays 
and  monographs  on  diseases  of  the  ear  in  the  Dublin  Journal  of 
Medical  Science,  the  Dublin  Quarterly  Journal,  and  the  London 
Medical  Times.f   The  substance  of  these  essays,  modified  by  sub- 

*  See  also  the  Author's  paper  on  the  Statistics  of  Deaf-dumbness,  communicated  to 
the  British  Association  at  Belfast,  September,  1852,  and  published  in  the  Journal  of 
the  Statistical  Society  of  London,  for  March,  1853. 

f  The  earliest  of  these  essays— Upon  the  Causes  and  Treatment  of  Otorrhoea, — that  by 
which  the  tubular  speculum  was  first  introduced  in  this  country, — appeared  in  the  First 


52  RKC0RD8  OF  CA8S8. 

sequent  knowledge,  and  amplified  by  whatever  improvenients  had 
been  made  in  the  art  since  their  publication,  I  have  reprinted  in 
this  work.  Those  diseases  of  the  ear  with  which  I  am  not  myself 
acquainted  I  have  briefly  enumerated  and  described,  and  given 
the  references  for  their  authenticity. 

In  an  art  but  just  emerging  from  the  mists  of  quackery,  which 
have  until  recently  enveloped  the  pathology  and  treatment  of 
diseases  of  the  ear,  it  is  of  great  importance  to  accumulate  facts, 
and  openly,  fairly,  and  fearlessly  to  state  the  truth,  even  at  the 
expense  of  what  is  termed  popular  reputation.  Observing  in  the 
periodicals,  from  time  to  time,  records  of  "cures**  of  deafness,  and 
aural  affections,  which  evidently  prove  their  authors  to  be  un- 
acquainted with  the  ordinary  pathological  appearances  of  such 
diseases ;  and  moreover,  seeing  daily  *'  causes  of  deafness**  put 
forward  in  books  and  papers,  which,  according  to  my  experience, 
rarely,  if  ever,  exist ;  and  furthermore,  hearing,  and  having  con- 
tinually brought  under  my  notice  (although,  curious  to  relate, 
generally  by  persons  who  are  themselves  incurably  deaf),  ac- 
counts of  success  in  the  treatment  of  deafness  in  other  parts  of  the 
United  Kingdom,  which  I  do  not  and  cannot  credit ; — I  determined 
to  make  an  accurate  note  of  every  case  of  disease  of  the  ear 
among  the  patients  who  applied  at  the  Hospital  for  twelve  months 
in  succession.  I  believe  it  to  be  of  the  greatest  importance,  in 
the  present  state  of  our  knowledge,  to  accumulate  facts,  and  to 
make  the  profession  at  large  acquainted  with  the  appearances 
which  any  deviation  from  the  normal  or  healthy  state  presents  in 
the  ear ;   and  I  have  also  thought  it  useful  to  fiuniliarize  the 

Series  of  the  Dublin  MedicAl  Journal,  for  January,  1844,  voL  xxiv.  p.  818,  as  Part  L 
of  **  Contributions  to  Aural  Surgery."  This  Essay,  which  met  with  a  very  fkvonrabls 
reception  on  the  Continent,  was  translated  into  German,  and  published  separately  by  Dr. 
Von  Uaselberg,  of  Stralsund,  in  1846,  and  afterwards  large  portions  of  it  were  translated 
by  Dr.  Schmalz,  of  Dresden,  in  1848.  Part  u. — Upon  the  Eariy  History  of  Aural  Snrgeiy, 
with  a  Nosological  Chart  of  Diseases  of  the  Ear,  already  referred  to  at  page  47 — was  pub- 
lished in  the  same  periodical  for  May,  1844.  Part  iii. — On  the  Inflammatory  Affections 
of  the  Membrana  Tyropani  and  Bliddle  Ear — was  printed  in  the  Dublin  Quarterly  Journal 
of  Medical  Science,  No.  viil,  for  November,  1847,  and  No.  XL,  for  February,  1848.  The 
Practical  Obser\'ations  on  Diseases  of  the  Ear,  with  the  records  of  cases  alluded  to  in  the 
text,  were  commenced  in  the  Medical  Times  for  Ifarch  29th,  1851,  and  have  been  oon- 
tinned  until  the  present  time. 


pupils  attending  the  Institution  over  which  I  am  pbu^ed  with 
those  methods  of  examination  which  will  best  enable  them  to  form 
an  accurate  diagnosis  and  prognosis. 

Each  case,  as  it  presented,  was  accurately  investigated  in  the 
presence  of  a  class  of  advanced  students  and  young  medical  men ; 
the  most  prominent  symptoms  were  noticed,  the  pathological  con« 
dition  of  the  parts  demonstrated,  and  a  few  remarks  made  upon 
the  cause  of  the  disease,  its  prognosis,  and  treatment.  Occa- 
sionally the  students,  under  my  direction,  conducted  the  examina* 
tion.  A  short-hand  writer,  familiar  with  medical  terms,  who  was 
always  in  attendance,  recorded  with  accuracy  what  passed.  These 
notes,  when  reduced  to  writing,  I  my  self  corrected,  and  frequently 
compared  with  the  appearances  presented  upon  the  patient's  next 
attendance.  By  this  means  a  vast  amount  of  time  and  labour  was 
saved,  and  the  diseases  being  thus  noted  by  myself,  without  the 
usual  intervention  of  a  *'  case-taker,**  I  believe  them  to  be  more 
accurate  than  those  usually  related  in  medical  writings.  By  this 
means  a  vast  amount  of  information  was  collected.  In  most  of 
these  clinical  cases  a  running  comment  is,  as  might  be  expected, 
mixed  up  with  the  description, — a  more  colloquial,  but  perhaps  not 
less  useful,  form  of  instruction  than  that  commonly  met  with  in 
medical  books  and  periodicals. 

As  far  as  progress  and  the  effects  of  treatment  are  concerned, 
many  of  these  cases  are  very  defective,  because,  in  a  burge  public 
Institution,  as  every  one  knows  who  is  extensively  engaged  in 
treating  the  poor,  it  is  not  possible  to  follow  out  their  history. 
Several  of  the  persons  applying  for  relief,  having  little  hope  held 
out  of  ultimate  restoration  to  perfect  hearing,  do  not  return  a 
second  time ;  others  are  kept  away  by  their  respective  avocations; 
and  many  of  them,  having  changed  their  residence,  have  found  it 
inconvenient  to  attend.  Unsatisfactory  as  these  drawbacks  are, 
and  must  always  be  under  the  like  circumstances,  I  think  the  pub- 
lication of  an  abstract  of  these  cases  will  be  so  far  useful,  by  en- 
abling the  profession  to  judge  from  what  causes  deafness  most 
usually  arises,  and  what  morbid  appearances  most  commonly 
present.  Some  of  these  cases,  exhibiting  types  of  disease,  have 
already  appeared  in  the  '*  Medical  Times." 

54  BSCORDS  OF  0A8BS. 

In  noting  these  cases,  in  some  instances  the  objective^  and  in 
others  the  subjective  symptoms,  have  been  first  recorded;  bat  the 
accounts  which  even  educated  people  give  of  the  history  of  thdur 
deafness  are  frequently  most  incongruous,  and  often  puxzling ;  and 
the  apathy  and  indifierence  with  which  persons  in  all  ranks  of 
life  have  allowed  the  insidious  approaches  of  aural  disease  to  cie^ 
upon  them  are  really  marvellous.  Mr.  Saunders,  with  whose 
luable  essay  upon  the  ear  I  wish  the  profession  were  better 
quainted  than  they  are,  remarked  upon  this  subject,  in  his  own 
peculiar  lucid  manner  of  expressing  himself,  nearly  half  a  cen- 
tury ago : — ** A  clear  and  distinct  recital  of  symptoms  is  rarely 
obtained  from  the  deaf  They  are  conscious  of  their  infimu^,  bat 
very  few  are  impressed  with  a  notion  that  hearing  may  be  im- 
paired by  a  variety  of  causes.  The  approach  of  deafness  is  inadions, 
and  often  unaccompanied  with  pain.  Few  strong  impresrions  are 
made  on  the  mind  of  the  patient,  and  he  loses  his  (iu^ulty  of  hear- 
ing so  imperceptibly,  that  in  general  his  friends  sooner  discover 
his  misfortune  than  himself** 

With  respect  to  the  mode  of  conducting  the  inquiry  in  the 
Hospital  cases,  I  may  remark,  that  where  a  patient  presented 
with  a  totally  Incurable  disease,  a  second  note  has  rarely  been  re- 
corded ;  indeed,  the  patient  has  always  been  discouraged  attend- 
ing the  Institution.  It  is  less  likely  to  bring  discredit  upon  the 
art  when  people  are  honestly  told  that,  owing  to  their  own  neglect^ 
or  to  their  improper  treatment,  the  time  has  passed  by  for  afibrd- 
ing  them  relief,  than  to  allow  them  to  continue  for  weeks  or 
months  in  attendance,  and  often  at  a  great  expense  of  time.  This 
observation  holds  good  in  private  practice  even  more  than  in  the 
management  of  institutions,  or  in  treating  the  poor. 

As  in  all  diseases,  so  especially  in  aural  affections,  the  first 
grand  point  is  accuracy  of  diagnosis,  without  which  all  treatment 
must  be  empirical,  and  to  arrive  at  which  it  is  indispensably  ne- 
cessary that  we  should  be  thoroughly  acquainted  with  the  best 
mode  of  conducting  an  examination.  For  that  reason,  and  be- 
cause it  is  in  it  I  find  both  the  practitioner  and  student  most  fre- 
quently at  fault,  I  have  in  the  following  pages  dwelt  at  greater 
length  and  entered  more  minutely  into  that  part  of  the  subject, 
than  is  usual  in  works  of  this  description. 


Passing  for  the  present  the  subjective  symptoms,  which  will 
best  appear  in  the  words  of  the  patient,  let  us  inquire  into  the  best 
method  of  forming  a  diagnosis  from  the  physical  signs  presented. 
The  patient  being  placed  opposite  strong,  direct  sun-light, — 
with  the  head  inclined  at  such  an  angle  that  the  sun^s  rays  may 
&11  directly  through  a  tubular  speculum  upon  the  membrana  tym- 
pani, — we  first  carefully  observe  the  condition  of  the  concha,  ex- 
ternal meatus,  mastoid  process,  infrazygomatic  region,  and  the 
space  immediately  below  the  lobe  of  the  ear.  The  auricle^  its 
various  folds,  its  colour,  its  temperature  in  particular,  its  thickness 
as  learned  by  feeling  its  hem  or  helix  between  the  fingers,  and 
the  angle  which  it  forms  posteriorly  with  the  cranium, — together 
with  the  position,  size,  shape,  and  colour  of  the  external  meatus^ 
as  seen  without  altering  the  relation  of  the  parts, — should  be  speci- 
ally noticed.  The  upper  rim  of  the  helix  should  then  be  grasped 
between  the  finger  and  thumb  of  one  hand,  and  drawn  upwards, 
backwards,  and  outwards,  while  the  thumbof  the  other  hand,  placed 
in  front  of  the  tragus,  by  drawing  it  and  the  integuments  forward 
upon  the  zygoma,  exposes  the  outer  third  or  more  of  the  auditory 
canal  to  view.  This  little  gorget-like  instrument  will  also  be 
found  useful 
in  examining 
the  external 
aperture.  The 
finger   should 

then  be  pressed  deeply  and  firmly  upon  the  moveable  root  of  the 
tragus^  and  backwards  into  the  depression  between  it  and  the 
articulation  of  the  jaw.  While  the  finger  is  retained  in  this  posi- 
tion the  patient  should  be  desired  to  open  and  shut  the  mouth| 
and  the  amount  of  pain  or  inconvenience  experienced  by  pressure 
in  those  two  different  positions  of  the  jaw  accurately  noted.  The 
middle  and  fore-fingers  should  likewise  be  inserted  deeply  behind 
the  ramus  of  the  jaw  towards  the  styloid  process,  and  notice 
taken  of  the  sensations  there  experienced. 

Where  we  have  reason  to  believe  inflammatory  action  exists, 
the  maMaid  process  in  an  especial  manner  claims  our  attention. 
Its  colour,  size,  shape,  and  temperature,  may  be  learned  by  even  a 


cursory  examination;  but,  besides  this,  it  should  be  moeicaiefiiUy 
pressed  upon  with  a  couple  of  fingers,  with  a  much  greater  d^iee  of 
force  and  firmness  than  is  usual  in  making  examinations  of  the  like 
nature  elsewhere ;  and  this  examination  should  not  only  be  applied 
to  the  mastoid  region,  but  to  the  whole  posterior  and  lateral  portion 
of  the  head,  if  we  have  reason  to  suspect  any  inflammation,  or  its 
effects.  The  insertion  of  the  sterno-mastoid,  as  well  as  the  upper 
third  of  that  muscle,  should  also  be  carefully  examined  in  the 
same  way,  as  there  is  a  small  gland,  in  shape  and  size  like  a  hone- 
bean,  situated  immediately  behind  the  auricle,  over  the  middle  of 
the  mastoid  process,  which  frequently  becomes  enlarged  during 
the  progress  of  aural  inflammations,  and  is  also  the  seat  of  violent 
neuralgic  pain  in  some  instances.  If  the  integuments  and  soft 
parts  are  swollen  or  (Edematous,  as  is  frequently  the  case  in  cer- 
tain inflammatory  affections  of  the  ear,  as  also  where  they  have  be- 
come thickened  from  long-continued  disease,  it  will  require  a  con- 
siderable degree  of  force  to  make  a  perfectly  satisfactory  exami- 
nation. The  amount  of  pitting  made  by  the  finger  during  this 
examination,  and  its  degree  of  permanency,  are  also  circumstances 
of  value  in  the  formation  of  a  diagnosis.  Percussion  of  the  mas- 
toid process,  immediately  behind  the  attachment  of  the  auricle, 
occasionally  affords  some  information,  as  will  be  shown  in  some  of 
the  cases  hereafter  detailed. 

We  next  proceed  to  inquire  into  the  condition  of  the  audUary 
canal,  and  external  surface  of  the  membrana  tympani.  To  effect 
this,  and  to  explore  every  portion  of  the  surface  of  these  partSi  it 
is  necessary  to  resort  to  the  mechanical  assistance  of  the  speculum ; 
first  taking  care  to  remove  any  impaction  of  wax,  accumulated  dis- 
charge, or  other  mechanical  impediment  which  may  exist  and  ob- 
struct our  vision.  If  this  obstruction  is  complete,  and  that  we  have 
reason  to  suppose  that  it  is  the  chief  cause  of  deafiiess,  the  em- 
ployment of  a  syringe  and  some  plain  warm  water  is  the  best  mode 
of  removing  it;  but  if  the  obstruction  merely  co-exists  with  other, 
and  particularly  with  some  of  the  inflammatory  affections  of  the 
meatus  or  tympanal  membrane,  or  if  it  be  only  partial,  and  con- 
sists of  portions  of  detached  cuticle,  hairs,  or  scales  of  hardened, 
inspissated  cerumen,  it  is  better  to  remove  these  gently  with  a 



pair  of  fine  foiceps,  because  the  very  act  of  syringing,  even 
with  wann  water,  caueee  in  a  healthy  car  an  inoteased  vascu- 
larity, which  will  mask  the  actual  amount  of  disease  present 
The  same  observation  applies  also  with  respect  to  alight  otor- 
rhoea,  but  if  there  be  much  discharge  present,  we  must  have  re- 
course to  the  syringe.  Having  found  that  the  handles  of  the 
instruments  introduced  through  the  tubular  speculum  and  the 
fingers  of  the  operator  interfere  to  a  certain  degree  with  the  direct 
eua-rays,  I  have  Utterly  had  instruments  constructed  with  an 
angle  in  (he  shaft,  as  showa  in  the  accompanying  view  of  a  pair 
of  ear  forceps,  the  utility  of  which  is  at  once  manifest. 

Up  to  a  very  recent  period  we  possessed  no  better  means  of 
examining  the  external  meatus  and  the  mcmbrana  tympani  than 
that  afforded  by  the  usual  ear  speculum,  made  somewhat  in  the 
form  of  a  crane-bill  forceps,  and  derived,  with  various  modifica- 
tions, from  the  time  of  Fabricius  Hildanus.  Itard,  DcleaUiVerret, 
Robbi,  Kramer,  and  others  have  improved  upon  this  speculum, 
which  was  that  in  general  use  in  this  country  until  I  introduced 
the  tubular  form  in  my  Essay  on  Otorrhcea.  Another  description, 
with  three  arms,  and  opening  by  a  screw  in  the  form  of  a  vagina 
speculum,  was  manufactured  by  Mr.  Weiss,  on  the  supposition 
that  the  external  auditory  passage  could  be  increased  in  caliber  by 
mechanical  means,  and  Hoffman  has  publislied  an  account  of  a 
somewhat  similar  instrument  in" CiMpcr'sFTocAenscfiri/if" for  1841. 
la  making  examinations  of  the  meatus  and  mcmbrana  tympani 
with  any  of  these  instruments,  the  chief  requisite  is  a  itnmff  dire<i 
light,  transmitted  without  interruption  to  the  tympanal  membrane, 
or  that  portion  of  the  passage  which  we  wish  to  examine.  This  is 
best  effected  by  means  of  the  sun's  rays,  but  as  the  ordinary  spe- 
calum  can  only  dilate  or  straighten  the  external  cartilaginous  por- 
Uoa  of  the  passage,  a  person  accustomed  to  aural  examinaUons  can 


frequently,  especially  where  the  meatuB  is  of  a  large  dae,  obaenre 
the  tympanal  membrane,  or  at  least  a  portion  of  it»  without,  as 
well  as  with,  such  an  instrument,  by  merely  lifting  up  the  auricle 
with  one  hand  and  pressing  the  tragus  forward  with  the  thmnb 
of  the  other.  The  light  must,  however,  be  strong,  and  made  to 
fiedl  directly  upon  the  passage.  In  all  such  examinations  tiie  patient 
should  be  seated  beneath  the  examiner,  with  the  head  slightly 
bent,  opposite  a  window  through  which  the  wn  is  M»dng  at  the 
moment,  and,  if  possible,  between  the  hours  of  eleven  and  three. 
Artificial  light  has  been  recommended,  but  it  is  not  so  re- 
quisite in  this  as  in  other  countries.  In  Vienna,  for  instance, 
during  the  winter  months,  there  are  many  days  on  which 
there  is  not  sufficient  sunlight  for  accurate  aural  examinations. 
Cleland  used  a  convex  glass,  which  was  held  before  a  wax  candle 
in  order  to  concentrate  the  rays  of  light  into  the  meatus.  To 
this  apparatus  Bozzini  added  a  concave  mirror,  but  without 
much  effect;  Deleau  further  modified  it  by  placing  a  lighted 
taper  between  two  concave  mirrors.  The  invention  of  the  instru- 
ment of  this  description  which  possesses  greatest  power  is  un- 
doubtedly due  to  our  countryman,  Buchanan,  the  principle  of 
whose  lamp  exhibits  an  evident  acquaintance  with  the  laws  of 
light,  and  the  mechanism  of  optical  instruments.  This  was  sub- 
sequently improved  upon,  and  its  effects  increased  by  Kramer, 
who  substituted  an  argand  lamp  for  tiie  comparatively  feeble  wax- 
light  of  the  original  inventor.  This  instrument,  which  in  form, 
construction,  and  effect,  very  nearly  resembles  a  common  magic 
lantern,  consists  of  a  tin  box,  having  its  interior  blackened,  and 
being  provided  with  a  strong  lamp  and  powerful  reflector,  op- 
posite which  there  is  a  tube  containing  two  convex  lenses,  each 
two  inches  and  a  half  in  diameter.  In  using  tiiis  apparatus,  a 
disc  of  strong  light,  about  the  size  of  a  halfpenny,  is  thrown  upon 
the  opening  of  the  meatus,  a  portion  of  which  light  is,  by  means 
of  any  of  the  ordinary  specula  straightening  the  cartilaginous  por- 
tion of  the  tube,  transmitted  to  the  membrane  of  the  drum.  Now, 
independent  of  the  inconvenience  of  this  lamp,  I  may  remark  that, 
although  it  undoubtedly  illuminates  the  passage  and  membrane 
very  powerfully,  yet  the  peculiar  lurid  glare  which  it  throws  upon 


every  object  decidedly  prevents  the  examiner  observing  with 
accuracy  those  conditions  of  the  parts — as  in  inflammation,  &c. — 
where  colour  and  the  character  of  the  vascular  arrangement  forms 
the  chief  means  of  true  diagnosis ;  and  even  Ejramer  himself  is 
forced  to  acknowledge  that  ''no  artificial  illumination  can  equal 
the  light  of  the  sun*s  rays,  or  render  this  light  imnecessary,  on 
which  account  it  must  always  be  had  recourse  to  in  important 
cases,  e.  g.  in  operations  in  the  vicinity  of  the  mcmbrana  tym- 
pani.^  All  lamps  possess  these  two  radical  defects : — One  is,  that 
although  an  irregularity  of  surface,  a  polypus,  an  aperture  in 
the  membrana  Qrmpani,  or  the  like,  may  be  detected,  yet  shades 
of  vascularity  produced  by  inflammation  or  congestion,  speckled 
opacities,  minute  points  of  morbid  deposit,  and  slight  ulcerated 
abrasions,  want  of  polish,  and  loss  of  transparency,  &c.,  cannot  be 
detected  by  their  means.  And  again,  although  we  were  able  to 
detect  an  ulcer,  a  granulation,  or  a  perforation,  we  could  not  be 
able,  while  the  eye  is  fixed  upon  the  spot,  to  apply  any  direct  re- 
medy to  the  part  affected, — or  pass  down  aporte-caustic,  a  forceps^ 
a  snare,  or  a  camel-hair  brush.  How,  for  instance,  could  a  hair,  no 
uncommon  cause  of  annoyance,  be  removed  off  the  surface  of  the 
drum  but  through  one  of  these  lamps?  No  obstetric  practitioner 
thinks  of  examining  the  os  uteri  or  the  surface  of  the  vagina  with 
a  lamp,  so  long  as  the  suti's  rays  can  be  directed  through  a  tubu- 
lar speculum  to  the  parts  affected. 

The  instrument  which  I  have  here  described  is  now  generally 
known  under  the  name  of  Kramer^s  ear  lamp.  Buchanan's  appa- 
ratus is  represented  in  his  "Illustrations  of  Acoustic  Surgery," 
and  all  the  various  lamps  and  forms  of  specula  are  figured  in 
Lincke's  Handbuch  der  Ohrendheilkundey  and  in  Frank's  Practiache 
AfUeUunfff  page  38  to  61.  In  most  modern  English  works,  how- 
ever, we  find  a  copperplate  of  ear  instruments,  particularly  those 
of  Kramer,  Lincke,  and  Schmalz,  but  in  addition,  though  without 
much  difference,  we  see  a  figure  of  "  the  author's  catheter,**  "  the 
author's  lamp,"  &c.  &c. 

Two  portable  ear  lamps  have  been  produced  in  England 
within  the  last  few  years,  one  by  Mr.  Jordan  of  Manchester,  a 
very  ingenious  instrument,  and  useful  when  artificial  light  is 


either  applicable  or  alone  available,  as  at  nighty  or  in  a  sick-room 
when  the  patient  cannot  be  moved  to  the  light  with  facilitj.  It 
consists  of  a  small  box,  containing  a  lighted  taper  and  two  me- 
tallic reflectors,  one  of  which  is  set  at  an  angle  in  the  bend  of  a 
projecting  arm,  which  throws  a  stream  of  light  on  the  membrana 
tympani,  through  a  fixed  tubular  speculum  inserted  into  the  mea- 
tus, while  the  operator  looks  through  a  narrow  tube  containing 
two  small  lenses ;  but,  like  all  such  instruments,  it  is  objectionable 
on  account  of  the  peculiar  red  glare  it  throws  upon  the  parts  under 
inspection.  Mr.  Averey's  reflector,  which  is  a  very  well^con- 
structed  instrument,  is  also  liable  to  the  same  objection. 

In  1827  Dr.  Newburg,  in  his  Memoir  d  ObsenxUUms  sur  la  Per- 
fonUion  de  la  Membrane  du  Tympany  published  at  Brussels,  recom- 
mended a  slender  horn  tube,  nearly  four  inches  long,  with  a  bell 
muzzle.  This  instrument,  which  is  much  too  long,  was  the  origin 
of  the  different  varieties  of  tubular  specula  now  in  use.  Subse- 
quently Dr.  Gruber,  of  Vienna,  improved  upon  Newburg's  idea, 
and  to  him  I  am  indebted  for  the  instrument  of  which  I  published 
an  account  in  1844. 

Having  found  that  all  the  instruments  heretofore  invented  for 
exploring  or  operating  upon  the  external  auditory  passages  were 
defective,  as  a  means  of  tranemittinff  lights  which  is  the  only  real 
object  of  a  speculum, — for  it  is  a  mistake  to  suppose  that  any  ap* 
paratus  can  do  more  than  straighten  and  dilate  the  external  aper- 
ture and  external  third  of  the  tube, — I  have  always  employed 
the  tubular  speculum  for  this  purpose.  This  little  instrument, 
formed  upon  the  principle  of  that  invented  by  Dr.  Newburg,  and 
described  in  the  preceding  paragraph,  I  first  saw  used  by  Dr. 
Gruber,  but  employing  it  as  he  did  with  the  artificial  light  of  Kra- 
mer*s  lamp,  he  had  not  the  same  opportunities  of  testing  its  value 
and  utility.  These  instruments  consist  of  conical  silver  tubes 
of  different  calibers,  such  as  those  represented  in  the  accom- 
panying wood-cut,  each  tube  or  speculum  being  an  inch  and  a 
half  long,  five-eighths  of  an  inch  wide  at  the  greater  aperture, 
and  varying  from  two  to  four  lines  in  the  clear  at  the  smaller  ex- 
tremity. Larger  and  smaller  sizes  will  be  occasionally  necessary, 
but  for  the  greater  convenience  of  carrying  in  the  pocket,  I  gene- 



rally  order  a  set  of  three,  fonned  so  as  to  fit  into  one  another,  and 
corresponding  in  size  to  the  representations  below.  They  should 
be  made  as  light  as  possible,  highly  polished  both  inside  and  out, 
with  a  stout  rim  or  burr  round  the  larger  margin,  and  the  smaller 
aperture  well  rounded  off,  so  as  not  to  irritate  the  ear  in  entering. 

I  have  tried  them  of  various  sizes  and  shapes,  and  their  sides  run* 
ning  at  different  angles,  as  well  as  with  the  interior  blackened, 
so  as  to  prevent  reflection  of  the  incident  luminous  rays,  but  those 
which  I  have  described  above  I  find  to  answer  the  purpose  best 
In  unng  this  speculum,  the  various  sizes  of  which  are  adapted  to 
different  ages  and  varieties  of  aural  aperture,  the  patient  must,  if 
possible,  be  seated  opposite  the  light,  and  the  head  placed  at  such 
an  angle  as  that  when  the  instrument  is  introduced  into  the  mea- 
tus, the  rays  of  light  will  fall  directly  through  it  upon  the  mem- 
brana  tympani.  While  the  auricle  is  drawn  upwards  and  back- 
wards with  one  hand,  this  little  tube  is  inserted  into  the  meatus  with 
the  other,  and  is  pushed  in  as  far  as  possible  without  giving  pain; 
the  head  of  the  patient  and  the  tube  also  are  then  moved  slightly 
irom  side  to  side,  and  the  inclination  or  obliquity  of  the  latter  al- 
tered till  a  full  stream  of  light  falls  upon  the  tympanal  membrane. 
In  making  this  examination  the  operator  must  be  careful  to  keep 
his  own  head  out  of  the  l^ht,  the  interference  of  which  is  a  very  fre- 
quent cause  of  failure  with  those  unaccustomed  to  aural  examina- 
tions;  the  shadow  of  the  head  should  fall  a  little  above  or  a  little 
below  the  sphere  of  the  speculum,  according  to  the  sun's  elevation 
at  the  moment;  and  I  need  hardly  mention  that  but  one  person 
can  make  this  exploration  at  a  time.     As  the  tube  is  generally 


arrested,  in  normal  ears  at  least,  by  the  narrow  portion  of  the  mea- 
tus at  the  junction  of  its  middle  and  external  thirds,  we  may  then, 
by  gently  rotating  and  moving  from  side  to  side  the  larger  aper- 
lure,  which  is  held  between  the  fingers,  direct  the  stream  of  l^hl 
so  as  to  play  upon  any  part  in  particular  all  round  the  meataa,  im- 
mediately external  to  the  membrana  tympani,  and  by  withdraw- 
ing it  slightly,  each  portion  of  the  passage  may  be  thus  accurately 
examined  in  detail.  By  this  means  every  part  of  1^  extcraal 
auditory  tube,  and  the  membrana  tympani,  and  even  the  position 
of  the  malleus  within  it,  may  be  as  distinctly  seen  and  as  carefully 
examined  as  any  portion  of  the  external  surftce  of  the  eye; 
whereas,  with  the  ordinary  hinge-moving  speculum,  I  have  in 
many  cases  been  unable  to  satbfy  myself  as  to  the  exact  oonditicm 
of  the  membrana  tympani ;  and  that  this  is  daily  experienced 
by  surgeons,  I  have,  in  addition  to  their  own  acknowledgments^ 
the  fact  of  cases  constantly  presenting  themselves,  in  which  a 
diagnosis  had  been  made  as  to  the  state  of  the  membrana  tym- 
pani, totally  at  variance  with  truth,  and  which  arose  firom  their 
inability  to  see  and  examine  it  with  the  usual  instruments.  To 
attempt  any  degree  of  dilatation  of  the  auditory  passage  by  means 
of  instruments  shows  a  want  of  anatomical  knowledge  in  their 
inventors,  as  the  most  any  speculum  can  effect  is  to  straighten  the 
external  cartilaginous  portion  of  the  tube,  and  thereby  allow  the 
light  to  play  upon  the  interior.  Had  the  accurate  and  honest- 
minded  Saunders  possessed  this  means  of  examining  the  ear,  he 
certainly  would  not  have  stated  that  he  had  '*  never  observed 
these  excrescences'*  (polypi  and  granulations)  *'  in  the  meatus  ex- 
temus  when  the  tympanum  was  sound.'*  Another  great  advan- 
tage which  this  funnel-like  speculum  possesses  over  all  others  is, 
that  it  remains  fixed  in  the  ear,  causing  scarcely  any  incon- 
venience, and  leaving  one  or  both  hands  free  for  the  application 
of  instruments  if  necessary.  It  is  also  much  more  easily  used  with 
young  children  than  any  other. 

From  a  long  and  most  extensive  use  of  the  tubular  speculum, 
I  am  convinced  that  it  is  not  only  the  simplest,  but  also  the  most 
effectual  instrument  for  examining  the  condition  of  the  membrane 
of  the  tympanum  and  the  external  auditory  canal.  Various  other 


instrumentSy  tubes  with  prisms,  such  as  that  invented  by  Mr. 
Warden,  and  mentioned  at  page  49,*  and  divers  lamps,  have  been 
recently  contrived,  and  their  virtues  set  forth  in  graphic  terms 
by  their  inventors  and  supporters,  but  they  are  all  comparative 
fiiilures,  because  they  cannot  enlarge  the  osseo-cartilaginous  por- 
tion of  the  canal  near  the  tympanum ;  and  the  prisms  are  totally 
unnecessary,  and  even  disadvantageous,  where  direct  light  can 
be  procured. 

I  have  dwelt  thus  long  upon  the  subject  of  the  speculum,  be- 
cause without  it  it  is  impossible  to  form  an  accurate  diagnosis, 
and  because  it  is  the  want  of  the  proper  employment  of  this  in- 
strument which  has  led  to  such  gross  errors  in  practice.  Modifi- 
cations of  it  have  been  devised  by  others,  and  possibly  in  their 
hands  they  may  be  found  more  useful  than  that  which  I  employ. 
I  believe,  however,  it  is  a  well-managed  light  (natural,  not  arti- 
ficial light),  a  practised  eye,  and  delicate  manipulation,  that, 
more  than  any  peculiar  form  of  instrument,  assists  the  practi- 
tioner effectually  to  explore  the  external  auditory  passage  or 
the  middle  ear,  and  which  enables  him  to  make  an  accurate 

It  is  no  small  gratification  to  me,  to  find  that  my  labours  to 
make  the  profession  in  this  country  acquainted  with  the  best  me- 
thod of  examining  ihe  ear  have  been  attended  with  some  success. 
An  ear  speculum  has  now  become  a  necessary  appendage  to  the 
assortment  of  instruments  which  a  surgeon  usually  carries  about 
with  him,  while  but  a  few  years  ago  such  a  thing  was  unknown — 
in  this  kingdom  at  least.  People  are  also  beginning  to  find  out  that 
something  may  be  done  for  deafness,  and  that  therefore  it  is  worth 
while  attending  to  diseases  of  the  ear  in  the  beginning.  I  do  not 
expect  that  the  prejudices  of  centuries  will  be  got  rid  of  in  a  day, 
nor  the  neglect  of  years  recovered  in  an  hour;  but  I  have,  within 
the  last  three  or  four  years,  observed  a  manifest  improvement  in 
the  mode  of  treating  diseases  of  the  ear  among  all  classes  of  the 

The  form,  curvature,  colour,  polish,  vascularity,  and  the  se- 

*  See  Medical  Gazette  for  24th  May,  1S44. 


crction  of  the  entire  auditory  canal  should  be  accurately  noted, 
and  having  brought  the  whole  of  the  passage  and  the  entire  of  the 
mcmbrana  tympani  under  our  view,  we  must  take  accurate  note 
of  their  relative  positions.  In  this  case  we  suppose  the  external  con- 
duit free  from  accumulation  of  wax,  muco-purulent  discharge,  or 
other  impediment  that  might  obstruct  our  view.  Should,  however, 
such  exist,  they  must  be  now  removed,  in  order  that  we  may  gain 
a  clear,  uninterrupted  sight  of  the  parts  they  cover.  Without  any 
abnormal  secretion,  however,  we  often  meet  with  so  much  cerumen 
as  parUally  interferes  with  the  examination,  and  this  may  be  gently 
removed  with  a  small  spatula  or  a  probe  rolled  round  with  cotton, 
as  by  syringing  in  such  cases  we  increase  the  vascularity,  and  so 
mask  the  natural  appearances. 

The  tympanal  inefnbrcau^  in  an  especial  manner,  claims  our 
attention ;  not  only  its  superficial  colour,  but  its  degree  of  trans- 
parency or  opacity,  its  tenuity  or  thickening,  its  vascularity, 
and  the  arrangement  and  position  of  its  vessels  in  every  part, — 
its  tension,  flexibility,  polish,  curvature,  and  its  position  as  re- 
gards the  interior  of  the  cavity,  of  which  it  forms  the  outward 
boundary, — and  also  the  direction  and  projection  of  the  handle  of 
the  malleus,  and  the  characters  of  the  membrane,  both  above  and 
below  the  attachment  of  this  bone,  should  be  carefully  observed. 
While  the  membrane  is  thus  within  the  field  of  the  speculum,  the 
patient  should  be  desired  to  try  and  press  air  into  the  drum  by 
holding  the  nose,  shutting  the  mouth,  and  making  a  forced  expi- 
ration. This  manoeuvre  should  be  resorted  to  several  times,  if  the 
first  be  ineffectual,  as  some  degree  of  tact  on  the  part  of  the  pa- 
tient is  necessary  to  test  the  experiment  The  sound  thus  pro- 
duced is  a  sort  odJiug^  and  very  much  resembles  that  of  a  dried 
bladder  suddenly  inflated  with  air.  In  order  to  become  familiar 
with  it,  one  should  practise  it  on  himself.  While  the  air  is  thus 
pressed  into  the  drum  we  should  note  accurately  whether  the 
membrane  vibrates,  or  its  tensity  is  altered,  and  if  so,  whether  it 
regains  its  original  position  suddenly  or  gradually.  The  patient^s 
own  sensations  should  likewise  be  taken  into  account  in  this  mat- 
ter. It  is  also  necessary  carefully  to  observe  the  degree  of  vascu- 
larity produced  by  this  inflation,  as  well  as  the  course  and  position 


of  the  vessels  which  cause  such  vascularity,  for  even  in  several 
healthy  ears,  if  this  experiment  is  made  two  or  three  times,  we 
seldom  fail  to  recognise  one  or  two  vessels  becoming  filled  with 
red  blood  along  the  course  of  the  malleus ;  and  if  a  small  aperture 
exists  in  the  membrane  which  may  have  previously  escaped  the 
eye,  we  may  then  readily  detect  it  both  by  sight  and  hearing. 
By  this  means  we  often  discover  a  perforation,  which,  from  its 
minuteness,  or  owing  to  the  part  being  thickened  or  coated  with 
discharge,  had  not  been  noticed  during  the  ocular  inspection. 
If  such  exist,  we  shall  then  see  its  open,  everted  lips  sometimes 
pressing  out  mucous  discharge,  and  also  hear  a  peculiar  whistling 
sound  which  the  air  makes  in  passing  through  this  narrow  aper- 
ture. There  are,  however,  some  cases  of  perforate  membrana 
tympani,  where,  from  obstruction  in  the  upper  part  of  the  Eusta- 
chian tube,  or  granulations  in  the  middle  ear,  this  cannot  be 
effected.  If  the  patient  be  able  to  inflate  the  tympanum  by  this 
method,  we  may  then  remove  the  speculum,  and,  applying  our 
own  ear,  either  directly  or  through  the  intervention  of  a  stetho- 
scope, placed  over  the  external  auditory  passage,  the  same  method 
of  inflation  should  be  again  had  recourse  to,  and  the  peculiarity 
of  sound  which  is  thus  produced  in  the  middle  ear,  whether  the 
ordinary  normal  rush  of  air,  or  a  prolonged  squeeling  or  gurgling 
sound,  such  as  might  be  caused  by  any  contraction  in  or  thicken- 
ing of  the  walls  of  the  Eustachian  tube,  or  by  dryness,  or  by  ac- 
cumulation of  mucus  either  in  it  or  in  the  cavity  of  the  tympa- 
num, is  heard.  The  stethoscope  should  also  be  applied  over  the 
mastoid  process,  and  the  same  scries  of  observations  made  upon 
the  sounds,  if  any,  produced  there ;  but  these  latter  can  seldom  be 
heard  distinctly. 

If  the  patient  be  unable  to  inflate  the  tympanum,  and  that  we 
have  reason  to  suspect  some  obstruction  of  the  Eustachian  iube^ 
or  an  accumulation  of  mucus,  blood,  pus,  or  other  matter,  in  the 
middle  ear,  we  may  then,  should  the  case  require  it,  proceed  to 
inject  air,  by  the  mechanical  means  of  a  pump,  an  elastic  tube, 
and  a  catheter,  into  the  cavity  of  the  tympanum,  while  we  care- 
fully note  the  result  by  means  of  a  stethoscope,  or  by  the  ear 
applied  externally.     It  must,  however,  be  particularly  borne  in 

66  THE  AIR-PRE88. 

mind,  that  if  the  patient  is  labouring  at  the  time  under  acute  in- 
flammation of  the  drum  or  its  membranes,  or  the  lining  of  the 
Eustachian  tube,  the  catheter  is  not  only  inapplicable,  but  highly 
injurious.  I  have  latterly  found  it  very  seldom  necessary  to  re- 
sort to  this  operation,  as  the  cases  in  which  it  is  applicable  are  of 
much  greater  rarity  than  is  usually  supposed,  or  as  the  works  of 
aurists  would  lead  us  to  believe.  Still,  as  exploration  through 
the  naso-tympanal  passage  is  a  valuable  means  of  diagnosis,  it 
should  be  here  described.  The  early  history  of  the  operation  has 
been  detailed  at  page  11.  A  great  variety  of  instruments  and  se- 
veral ingenious  machines  have  been  invented  for  injecting  atmos- 
pheric air,  gases,  medicated  vapours,  and  fluids,  into  the  middle 
ear  through  the  Eustachian  tube.  These  consist  of  catheters  of 
different  curves  and  calibers,  and  formed  of  flexible  and  inflexible 
materials,  and  a  great  diversity  of  complicated  mechanical  appa- 
ratus for  pressing  air  or  fluids  through  these,  from  a  simple  blad- 
der or  elastic  bag,  or  a  bellows,  to  an  air-press,  which  com- 
presses and  condenses  a  certain  volume  of  atmospheric  air  by 
means  of  a  forcing-pump  into  a  chamber  furnished  with  a  stop- 
cock, to  which  the  catheter  may  be  connected  through  the  me- 
dium of  a  flexible  tube.  That  devised  by  Kramer,  and  figured 
in  his  work,  is  by  far  the  best  and  most  easily  managed.  The 
pump  which  I  am  in  the  habit  of  using  was  manufactured  for  me 
in  1841  by  Mr.  Weiss,  and  is  figured  at  page  70.  It  may  not  be 
so  easily  managed  as  that  of  Kramer,  in  which  the  piston  rod  is 
worked  by  a  long  lever,  but  it  possesses  the  advantage  of  having 
the  receiver  quickly  and  more  effectually  charged.  This  instru- 
ment is  fourteen  inches  high,  exclusive  of  the  piston  rod,  and 
four  and  a  half  in  diameter.  The  cylinder  of  the  force-pump, 
which  rises  above  the  surrounding  receiver,  and  passes  into  it  for 
about  two-thirds  of  its  depth,  is  provided  with  valves  through 
which  the  air  is  accumulated  in  the  latter  to  the  required  extent 
Generally  six  or  seven  actions  of  the  piston  is  sufficient  for  this 

The  catheter  which  I  am  in  the  habit  of  using  with  adults  is 
that  here  figured  of  the  natural  size ;  smaller  ones  may  be  required, 
but  a  silver  instrument  like  this,  well  smoothed  and  rounded  at  the 


point,  and  of  as  large  a  size  as  can  with  facility  be  introduced 
through  the  nose,  is  less  likely  to  do  mischief,  causes 
less  irritation,  is  less  liable  to  catch  in  the  mucous 
membrane,  and  is  more  apt  to  adjust  itself  to  the  bell 
or  trumpet-shaped  mouth  of  the  Eustachian  tube,  than 
one  of  a  smaller  size,  or  composed  of  a  flexible  mate- 
rial. Even  the  elastic  catheter  can  only  be  introduced 
with  a  stilette,  the  withdrawal  of  which  causes  consi- 
derable irritation,  and  generally  disadjusts  the  point 
of  the  instrument.  Some  people  even  at  the  present 
day  assert  that  the  catheter  can  be  introduced  through 
the  mouth,  and  others  recommend  it  to  be  passed 
above  the  lower  turbinated  bone  of  the  nose.  And 
again  we  hear  it  stated  that  the  instrument  being  once 
fixed  in  the  Eustachian  tube,  it  will  remain  there,  or 
the  patient  may  be  directed  to  hold  it  in  that  position 
until  an  inflated  bladder,  a  bellows,  a  syringe,  or  a 
gum-elastic  bag,  charged  with  fluid,  is  attached  to  its 
extremity,  and  the  contents  discharged  through  it  into 
the  middle  ear.  It  would  occupy  too  much  space  to 
enter  minutely  into  the  objections  to  each  of  these 
statements  or  modes  of  proceeding.  I  do  not  believe 
they  are  generally  feasible,  and  this  is  an  opinion  in 
which  I  am  sure  the  most  experienced  aural  surgeons 
will  agree  with  me.  Along  the  floor  of  the  nose  is, 
in  the  first  instance,  the  most  ready  access  to  the 
Eustachian  tube ;  but,  supposing  that  we  have  passed 
the  instrument  with  the  greatest  facility,  and  are  quite 
sure  that  the  beak  has  turned  into  its  faucial  opening, 
we  must  always  bear  in  mind  that  not  much  more 
than  half,  or  at  most  three-quarters,  of  an  inch  of  the 
curved  portion  of  the  instrument  has  passed  up  into 
the  tube,  and  that  the  slightest  movement  on  the  part 
of  the  patient,  either  of  the  anterior  naris,  which  is 
irritated  by  the  foreign  body,  or  the  top  of  the  pha- 
rynx, where  all  the  parts  concerned  in  deglutition  are  more  or 
leas  strained  and  excited,  may  disadjust  the  instrument.     The 



slightest  effort  at  deglutition,  even  the  act  of  swallowing  the  saliva, 
will  often  effect  this,  as  we  may  perceive,  by  observing  the  altera- 
tion in  the  position  of  the  ring  at  the  end  of  the  catheter  which 
projects  beyond  the  nose.  It  fortunately  so  happens,  that  nausea 
is  seldom  produced  if  the  instrument  has  been  carefully  and 
delicately  introduced.  In  order,  however,  to  obviate  the  diffi- 
culties which  I  have  just  referred  to,  and  to  keep  the  instrument, 
when  once  properly  adjusted,  fixed  in  the  right  place,  mechanical 
contrivances  have  been  devised,  of  which  a  sort  of  vice — the  plate 
of  which  is  fastened  upon  the  forehead,  immediately  above  the 
root  of  the  nose,  by  means  of  a  leather  strap  furnished  with  a 
buckle,  which  passes  round  the  head — is  the  handiest.  Upon  the 
front  of  the  metallic  plate  is  a  ball-and-socket  joint,  in  which  re- 
volves the  little  vice,  or  forceps,  which  is  set  on  at  a  right  angle, 
and  should  come  down  over  the  anterior  opening  of  the  nose. 

The  patient  being  seated  in  a  chair  with  the  head  supported 
against  a  high  back,  specially  constructed  for  the  purpose,  and 
the  fix)ntlet  put  on  as  I  have  described, — with  the  fore-finger  of 
the  left  hand  elevate  the  point  of  the  nose,  and  then  with  the 
right  hand  insert  the  catheter,  with  its  beak  turned  outward  into 
the  angle  between  the  floor  and  external  wall  of  that  cavity ;  pass- 
ing it  rapidly  over  the  floor  of  the  nose,  a  dexterous  and  well- 
practised  operator  will  frequently  hitch  it  into  the  sulcus  of  the 
Eustachian  opening  at  the  first  attempt,  and  is  conscious  of  the 
fact  by  that  tactus  eruditus  which  nothing  but  extensive  ex- 
perience can  give,  but  which  it  is  very  difficult  to  describe.  We 
can  often  feel  the  catheter  grasped  by  the  mouth  of  the  Eusta- 
chian tube.  If,  however,  we  have  missed  the  aperture,  we  roust 
push  on  the  catheter  until  it  is  arrested  by  the  back  of  the  pha- 
rynx ;  then  turn  the  beak  downwards,  and  withdraw  the  instru- 
ment a  little,  until  its  concavity  hitches  against  the  edge  of  the 
hard  palate,  and  then,  again  making  a  slight  sweep,  and  turning  the 
beak  outwards  and  a  little  upwards,  and  at  the  same  time  pushing 
it  slightly  in  and  out,  and  thus  feeling  for  the  opening,  we  will, 
after  a  little  practice,  succeed  in  our  attempt.  We  must,  however, 
remember  that  we  have  to  deal  with  parts  which  vary  in  length 
and  caliber  in  diflcrent  individuals.     We  may  always  be  aware  of 


the  direction  of  the  beak  by  looking  to  the  ring  at  the  end  of  the 
catheter,  as  they  are  both  on  the  same  plane.  We  may  now  be 
conscious  that  the  instrument  has  acquired  the  desired  position, 
and  that  its  beak  is  in  the  pharyngeal  extremity  of  the  Eusta- 
chian tube ;  but  yet,  until  we  make  a  further  experiment  with  a 
jet  of  air,  we  are  not  perfectly  certain  that  it  is  in  the  exact  posi- 
tion which  we  desire,  as  the  open  extremity  of  the  instrument  may 
be  pressing  against  the  thickened  or  flaccid  mucous  membrane  of 
the  part.  Now  let  us  suppose  that  the  instrument  has  gone  in 
with  facility,  that  the  patient  is  steady,  and  has  a  well  formed 
nose,  and  has  not  expressed  any  sign  of  uneasiness, — we  must 
not,  however,  let  him  speak,  for  the  very  act  of  so  doing  might, 
until  the  instrument  is  properly  flxed,  disadjust  its  point. 

There  is  much  variety  in  the  nasal  organ,  and  in  a  great 
number  of  instances  the  septum  is  not  in  the  middle  line :  I  have 
met  cases  in  which  the  vomer  leaned  over  to  one  side,  generally 
the  left,  so  that  the  aperture  was  too  narrow  for  the  passage  of  the 
instrument ;  and  in  other  cases  the  lower  spongy  bone  came  down 
80  low,  and  encroached  so  much  upon  the  nasal  cavity,  that  a 
similar  obstruction  was  produced.  The  chief  point  of  irritation  is 
at  the  anterior  extremity  of  the  nose,  and  therefore  it  is,  that  we 
must  press  up  its  point  with  the  finger  of  the  left  hand,  and  also 
pass  the  instrument  with  rapidity  over  this  portion  of  its  transit. 
If  the  operation  be  properly  conducted,  it  is,  though  an  un- 
pleasant sensation,  by  no  means  painful,  and  even  sneezing  is 
seldom  produced ;  but  there  is  another  symptom  which  almost  in- 
variably attends  the  introduction  of  the  catheter,  that  is,  lachryma- 
tion; — we  constantly  see  a  tear  flowing  over  the  cheek;  it  is  not 
the  effect  of  pain,  otherwise  both  eyes  would  weep,  for  it  seldom 
or  never  occurs  except  upon  the  side  on  which  we  are  operating, 
and  it  appears  to  be  the  effect  of  irritation  of  the  mucous  mem- 
brane continuous  with  the  conjunctiva  and  conveyed  along  the 
course  of  the  excretory  lachrymal  duct.  It  is  usual  to  warm  the 
catheter  by  holding  it  near  the  fire,  or  rubbing  it  briskly  through 
the  fingers ;  but  as  the  parts  over  which  it  passes  are  always  well 
lubricated  with  mucus,  and  do  not  grasp  the  instrument  like  the 


urethra,  I  do  not  think  it  necessary  to  oil  the  catheter,  as  some  re- 

Having  proceeded  thus  far,  turn  down  the  clams  or  forceps, 
and,  leaving  the  catheter  free  for  a  moment,  grasp  it  with  the 
blades  of  the  former,  and  screw  home  the  nut  which  tightens  them, 
and  tlien  fix  the  apparatus  by  means  of  the  screw  which  arrests 
the  motion  of  the  bali-and-sockct  Joint  upon  the  forehead  plate. 
Upon  a  small  table  in  front  of  the  patient  is  placed  the  air-press, 
the  mechanism  of  which  has  been  already  explained,  and  which 
had  been  previously  charged,  and  to  which  the  elastic  tube, 
about  two  feet  in  length,  is  screwed  by  a  stop-cock  communi- 
cating with  the  receiver.  To  the  other  extremity  of  the  tube  is 
fixed  a  small  brass  ferrule  which  fits  into  the  end  ofths  catheter,  in 
connecting  it  with  which  considerable  care  and  nicety  is  required. 

The  catheter  being  held  between  the  finger  and  thumb  of  the  left 
hand,  the  ferrule  should  be  delicately  but  firmly  inserted  into  it 
with  the  right.  An  assistant  or  the  patient  should  tlien  hold  up 
this  connecting  tube,  lest  its  weight  might disadjust  the  catheter's 
point;  the  position  of  the  ring  at  the  other  end  of  which  will 
always  show  its  position.  This  ring  should  point  outwards  and  a 
little  upwards,  nearly  on  a  line  with  the  external  meatus,  but  the 
augle  which  it  makes  with  the  honzon,  supposing  the  patient  to 


sit  in  a  natural,  erect  position,  will  very  much  depend  upon  the 
formation,  and  especially  the  length,  of  the  external  naris.  The 
illustration  upon  the  previous  page  shows  the  application  of  the 
apparatus,  and  serves  to  explain  the  foregoing  description. 

Before  we  apply  the  ear  or  the  stethoscope  to  the  patient*s  ear, 
we  should  partially  turn  the  stop-cock,  so  as  to  let  a  little  air  pass 
through ;  for  frequently,  especially  if  the  patient  is  at  all  nervous, 
the  first  jet  of  air  may  cause  him  to  start,  and  perhaps  to  derange  the 
catheter.  The  operator  should  now  apply  the  bell'd  extremity 
of  the  stethoscope  over  the  concha,  by  which  means  its  bore  is 
almost  directly  over  the  external  meatus;  and  having  applied  his 
ear  to  the  other  end  of  it,  he  should  turn  the  stop-cock  of  the 
air-press  with  his  own  hand,  and  thereby  regulate  with  greater 
precision  the  force  and  volume  of  the  stream  of  compressed  air 
which  passes  up.  By  this  mode  of  manipulation  alone  am  I 
convinced  of  the  fact  of  the  air  passing  into  the  cavity  of  the 
middle  ear;  and,  until  this  test  is  applied,  I  do  not  believe  that 
any  one  can  say  with  certainty  that  the  air  has  freely  passed  up. 

In  a  healthy  ear,  with  a  free  tube,  when  a  stream  of  air  is  passed 
into  the  tympanum  after  this  fashion,  it  impinges  upon  the  inner 
wall  of  the  membrana  tympani  with  a  peculiar  thug^  followed  by 
a  continuous  rustling  sound,  which  is  very  remarkable,  and,  once 
heard,  is  not  easily  forgotten.  This  is  the  natural  sound,  and  devia- 
tions from  it,  caused  by  stricture,  or  obstruction  of  the  Eustachian 
passage,  by  a  diseased  condition  of  the  membrane  lining  the  mid- 
dle ear,  or  by  collections  of  mucus,  pus,  or  other  fluids  in  that 
cavity,  produce  abnormal  sounds  of  a  squeeling,  rasping,  or  a  gurg- 
ling character,  which  are  of  value  in  diagnosing  aural  affections. 
These  sounds  may  perhaps  in  time  be  reduced  to  some  degree  of  or- 
der, and  we  should  familiarize  ourselves  with  them,  so  that  if  possible 
we  may  be  able  to  test  and  appreciate  their  value.  Laennec  was 
well  acquainted  with  the  phenomena  of  these  sounds,  and  anti- 
cipated that  auscultation  would  become  a  useful  adjunct  in  deter- 
mining not  merely  the  condition  of  the  Eustachian  tube,  but  also 
the  state  of  the  tympanum. 

We  should  now  place  the  patient  in  such  a  position  that  we 
may  have,  through  the  ordinary  tubular  speculum,  a  clear  view  of 


the  external  surface  of  the  membrana  tympani,  and  we  shall  then 
perceive,  that  when  we  permit  a  jet  of  air  to  reach  the  cavity 
of  the  tympanum,  it  presses  outwards  the  anterior  and  lower  por- 
tion of  the  membrane, — that  which  is  most  vibratory  and  placed 
opposite  the  stream  of  air, — and  also  that  it  at  the  same  time 
renders  the  upper  and  posterior  part  of  the  membrane  slightly 

Were  we  to  allow  too  great  a  stream  to  pass  through  the  tube, 
the  desired  object  would  not  be  effected ;  the  current  of  air,  not 
able  to  find  entrance  through  the  Eustachian  tube,  would  force 
back  and  disadjust  the  mouth  of  the  catheter  with  a  loud  gurgling 
noise  like  that  heard  when  gargling  the  throat,  and  cause  consi- 
derable annoyance  and  even  pain  to  the  patient  by  its  regurgi- 
tation. Therefore  it  is  that  the  operator  should  with  his  own  hand 
regulate  the  force  of  the  current,  while  at  the  same  time  he  listens 
to  its  effect  upon  the  ear. 

To  remove  the  instrument  we  must  proceed  with  the  same 
caution  and  delicacy  with  which  we  introduced  it;  first  by  gently 
separating  the  connecting  tube  from  the  catheter ;  then  freeing 
the  latter  from  the  blades  of  the  vice  or  forceps,  and,  having 
pulled  it  forward  a  short  distance,  the  beak  should  be  turned 
downward  and  the  instrument  so  withdrawn. 

This,  then,  is  the  operation  about  which  we  have  heard  so 
much,  and  from  which  death  is  said  to  have  occurred  in  two  in- 
stances in  London,  some  years  ago.  Simple  and  easy  of  perfor- 
mance, however,  as  it  now  seems,  I  must  suppose  that  it  is  occa- 
sionally performed  with  roughness,  and  even  violence.  I  remem- 
ber a  few  years  ago  seeing  a  dragoon  officer,  who  laboured  under 
raucous  accumulation  of  the  ears,  and  as  he  was  himself  unable  to 
force  air  into  the  tympanal  cavity,  it  was  deemed  advisable  to  re- 
sort to  the  operation  which  has  been  just  described.  Accordingly, 
I  desired  an  assistant  to  bring  in  the  air-press,  while  I  proceeded 
to  arrange  the  other  preliminaries,  merely  informing  the  patient 
that  it  was  necessary  to  make  an  examination  which  would  put 
him  to  a  little  inconvenience,  but  not  cause  any  pain.  He  eyed 
the  preparations  with  considerable  anxiety,  and  at  last  exclaimed, 
"  Oh !  I  know  now  what  you  are  going  to  do,  and  I  am  deter- 


mined  not  to  have  that  thing  rammed  up  my  nose  again ;  for  the 
last  time  it  was  done  I  was  put  to  such  pain  and  bled  so  much 
that  I  fainted."  We  have  known  such  things  occur  to  rough  and 
ignorant  practitioners  in  their  endeavours  to  force  a  catheter  into 
the  bladder,  and  the  mention  of  this  circumstance  is,  I  feel,  suffi- 
cient to  put  us  on  our  guard;  and  I  think  I  need  scarcely  add, 
that,  where  such  force  and  violence  as  that  detailed  by  this  gen- 
tleman were  employed,  the  original  object  of  the  operation  could 
not  have  been  attained. 

We  have  all  heard  a  great  deal  about  catheterism  of  the  Eus- 
tachian tube— of  the  marvellous  and  instantaneous  effects  attri- 
buted thereto,  of  the  accidents  which  may  occur,  and  of  the  diffi- 
culties which  beset  the  operator  in  his  endeavour  to  introduce  an 
instrument  into  the  faucial  opening  of  the  passage  which  leads 
into  the  middle  ear.  I  know  few  subjects  upon  which  there  is 
more  general  ignorance  than  the  value  to  be  attached  to  Eusta- 
chian catheterism,  or  the  best  mode  of  employing  it.  Some  wri- 
ters would  lead  us  to  suppose  that  this  operation  is  of  use  in  a  far 
greater  number  of  aural  diseases  than,  according  to  my  experience, 
is  the  fisu^t.  In  order  to  facilitate  our  diagnosis,  they  would  have 
us  explore  the  middle  ear  by  the  air  douchey  a  jet  of  water,  or 
a  solid  instrument,  in  almost  every  case  that  presents.  Errors 
of  commission  are,  in  both  medicine  and  surgery,  I  believe, 
of  much  greater  injury  than  those  of  omission ;  and  theintroduc- 
tion  of  a  foreign  body  into  the  Eustachian  tube,  forcing  a  volume 
of  cold  air,  or  injecting  a  quantity  of  fluid,  even  warm  water, 
into  the  cavity  of  the  middle  ear,  as  some  recommend  and  say  they 
practise,  is,  in  nearly  all  cases,  while  inflammatory  action  is  going 
forward  in  the  parts  submitted  to  the  process,  unnecessary  and  fre- 
quently injurious.  Again,  the  mode  in  which  I  have  heard  both 
patients  and  bystanders  speak  of  instruments — catheters  of  various 
kinds,  gum-elastic,  and  metallic,  and  even  solid  sounds,  some  of 
the  latter  much  larger  than  the  bore  of  the  aural  end  of  the  Eus- 
tachian tube  even  in  the  dry  bone — being  introduced  into  the 
middle  ear,  in  order  to  explore  that  cavity,  to  wash  out  its  con- 
tents, or  to  break  up  collections  of  mucus  within  it,  or  to  dilate 
strictures  and  contractions  of  the  tube  itself,  convinces  me  that 


the  desired  object  was  not,  fortunately  for  the  sufferers,  obtained. 
Even  Kramer  speaks  of  pushing  a  catgut  bougie,  introduced 
through  the  Eustachian  tube,  "  between  the  handle  of  the  malleus 
and  the  incus" !  People  are,  however,  beginning  to  find  that  this 
attempt — for  I  know  in  many  cases  it  is  only  an  attempt — to 
force  solid  or  fluid  substances  into  the  cavity  of  the  drum,  is  as  in- 
effectual to  remove  deafness  as  the  almost  indiscriminate  excision 
of  the  tonsils — since  preserved  in  pickle-pots — recommended  for  a 
like  purpose  a  few  years  ago,  has  proved  to  be.  I  have  heard  of 
cases  in  which  the  middle  ear  has  been  said  to  be  explored  by 
such  mechanical  means,  even  in  this  country,  and  I  have  been 
shown  steel  sounds  manufactured  for  the  purpose.  Such  instru- 
ments are,  however,  with  the  exception  of  the  tearing  and  in- 
flammation which  they  may  cause  in  the  nasal  extremity  of  the 
tube,  harmless,  for  they  could  not  by  any  possibility,  even  in  the 
dead  subject,  be  passed  through  the  upper  end  of  the  Eustachian 
tube.  We  should  bear  this  rule  ever  in  remembrance  before  ex- 
ploring the  middle  ear ;  it  is  one  which  Sir  A.  Cooper  observed 
to  me  many  years  ago,  and  I  have  ever  since  acted  upon  it : — 
Whenever  the  patient  is  himself  able  to  inflate  the  tympanum,  never 
use  any  artificial  means  to  do  so ;  it  is  unnecessary  and  may  be 
injurious.  Let  me  to  this  aphorism  add  another,  to  which  I  have 
already  alluded,  and  which  surgeons  would  do  well  to  remember. 
Where  there  is  reason  to  believe  that  the  cavity  of  the  drum  is 
inflamed,  carefully  abstain  from  all  poking  with  catheters,  or  any 
attempt  to  introduce  foreign  substances  into  that  delicately-orga- 
nized portion  of  the  animal  machine.  As  good  general  surgery 
teaches  us  to  avoid  the  introduction  of  instruments  through  an 
inflamed  urethra,  or  into  an  irritable  bladder,  so  ought  judicious 
aural  surgery  teach  us  to  abstain  from  meddling  in  the  cases  to 
which  I  have  alluded.  The  only  solid  instrument  with  which  I 
now  ever  venture  to  explore  the  Eustachian  passage,  and  that 
for  only  a  short  distance,  is  an  ivory  bougie,  rendered  flexible  by 
having  the  earthy  matter  removed  by  immersion  in  an  acid,  and 
the  point  of  which  for  an  inch  at  least  had  been  previously  sof- 
tened in  water  so  as  to  resemble  apiece  of  gelatine.  A  large-sized 
catheter  should  be  first  introduced,  and  the  bougie  passed  up 


through  it;  but  stricture  of  the  Eustachian  tube  is  so  exceedingly 
rare,  and  so  difficult  to  recognise  during  life,  that  the  surgeon  is 
very  seldom  called  on  to  practise  such  an  operation. 

In  connexion  with  Eustachian  catheterism  should  be  men- 
tioned, the  mode  of  injecting  fluids  for  the  purpose  of  washing 
out  the  tube  and  the  middle  ear,  in  case  of  impaction  of  the 
former,  or  mucous  accumulation  in  the  latter ;  and  of  intro- 
ducing gases,  etherous  vapours,  resinous  and  other  volatile  sub- 
stances, for  the  purpose  of  altering  the  condition  of  the  mucous 
membrane,  or  stimulating  the  nervous  expansion  on  its  sur- 
face. A  simple  elastic  bag,  with  the  nozzle  adapted  to  the  end  of 
the  catheter,  will,  for  those  who  may  be  inclined  to  practise  it^ 
effect  all  that  is  required  or  that  can  be  attained  by  syringing  out 
the  tympanum :  in  general  I  believe  the  fluid  seldom  reaches  that 
point,  while  it  causes  great  irritation  by  regurgitating  into  the 
throat;  but  in  order  that  it  may  have  a  fair  chance  of  going  into 
the  middle  ear,  the  catheter  ought  to  be  fixed  by  the  frontlet 
as  already  described.  Supposing  we  may  with  safety  explore  the 
Eustachian  tube,  and  endeavour  by  artificial  means  to  press  a 
column  of  air  or  a  jet  of  fluid  into  the  middle  ear,  and  thereby 
free  it  of  its  extraneous  contents,  and  restore  to  its  natural  posi- 
tion the  vibrating  portion  of  the  tympanal  membrane,  it  will  be 
of  little  avail  to  effect  these  objects, — as  it  would  be  merely  to  press 
out  the  contents  of  the  lachrymal  sac  in  a  case  of  mucocele,  or 
chronic  inflammation  of  the  mucous  membrane  of  that  cavity, — 
\mless  we  at  the  same  time  make  use  of  such  means,  both  topically 
and  constitutionally,  as  shall  restore  the  healthy  character  of  the 
lining  membrane,  which  evidently  participates  in  the  diseased 
action,  and  of  which  manifest  traces  are  observable  upon  the  ex- 
ternal aspect  of  the  membrana  tympani. 

For  vaporizing  the  tympanum  a  variety  of  ingenious  contri- 
vances have  been  invented,  especially  by  the  continental  aurists, 
consisting  of  air-tight  jars  containing  gas,  connected  with  the  ca- 
theter by  elastic  tubes,  or  vessels  shaped  like  retorts,  in  which  the 
substances  to  be  vaporized  are  placed,  fixed  upon  the  ordinary 
chemical  stands  over  spirit-lamps.     These  shall  be  more  particu- 

76  BTRUlalHG. 

Urly  considered  in  the  section  relating  to  "nervous  deafness," 
the  disease  for  which  such  fumigations  arc  said  to  be  applicable. 

In  the  previous  description  of  the  method  of  examining  the 
external  and  middle  ear  it  has  been  prcsumod  that  the  external 
ftuditory  conduit  is  free ;  it  may,  however,  and  it  often  does,  hap- 
pen, that  we  are  unable  to  explore  the  passage,  or  obtain  a  view 
of  the  membrana  tjmpani,  owing  to  obstruction  of  the  former 
with  cerumen,  collections  of  hur,  or  thickened  and  detached  epi- 
thelium, the  muco-purulent  secretion  consequent  upon  otorrhcca, 
or  foreign  bodies  of  any  description ;  and  therefore  it  is  sometimes 
necessary  to  have  recourse  to  the  operation  of  syringing  merely 
to  assist  our  dit^nosis.  Simple  as  this  operation  may  appear,  and 
frequently  as  it  ia  resorted  to  by  uneducated  persons,  it  is  one 
which  requires  some  degree  of  tact,  caution,  and  dexterity,  in  its 

To  avoid  slopping  in  syringing  the  ears,  I  have  found  the 
form  of  vessel  represented  below  very  useful:  it  is  metallic,  six 
inches  long,  four  broad,  and  two  deep ;  its  concave  part  Gts  accu- 
rately the  curve  beneath  the  lobe  of  the  ear,  and  the  perforated 
septum  strains  the  clean  water  from  the  dirty.  If  held  by  the 
patient  in  the  proper  position,  closely  applied  to  the  cheek,  no 
water  can  get  down  by  its  side. 

The  top  of  the  auricle  should  be  grasped  with  the  left  hand, 
and  drawn  slightly  upwards,  outwards,  and  forwards,  so  as  to 
assist  in  straightening  the  auditory  canal;  and  then  we  can  inject 


B  Steady  stream  of  water,  the  thumb  raising  and  depressing  the 
piston  by  means  of  a  brass  syringe,  capable  of  holding  three  or  four 
ounces  of  fluid,  but  so  constructed,  as  shown  in  the  accompany- 
ing cut, — with  a  pair  of  loops  attached  to  its  upper  extremity, 
through  which  the  fore  and  middle  fingers  are  passed, — that  it 
may  be  worked  with  facility  by  the  right  hand. 

This  instrument  is,  however,  only  suited  to  the  hands  of  a 
surgeon.  The  small  pewter,  bone,  and  glass  syringes  are  really 
of  little  or  no  use.  The  gum-elastic  bag  is  the  safest  for  general 
use ;  but  I  do  not  think  it  possible  for  any  one  effectually  to 
syringe  his  own  ear. 

In  some  persons,  syringing,  or  the  mere  introduction  of  a  spe- 
culum, induces  violent  paroxysms  of  coughing ;  in  others,  the 
simple  act  of  injecting  tepid  water  will  produce  syncope,  although 
such  patients  tell  us  that  it  is  not  from  the  pain  they  feel.  The 
removal  of  a  granulation,  or  a  small  polypus  from  the  external 
auditory  passage,  will  at  times  produce  sickness  of  stomach,  weak- 
ness, and  even  fainting. 

There  is  a  circumstance  connected  with  this  part  of  the  aural 
examination  worthy  of  attention.  We  often  observe  that,  during 
the  removal  of  wax,  in  syringing  or  in  any  way  interfering  with 
the  meatus,  the  patient  is  seized  with  a  fit  of  spasmodic  coughing, 
apparently  caused  by  some  irritation  in  the  larynx,  and  we  can 
reproduce  the  phenomenon  simply  by  the  introduction  of  a  probe, 
and  touching  ever  so  gently  a  particular  spot  upon  the  surface 
of  the  meatus.  This  is  not  a  very  unusual  phenomenon,  al- 
though it  cannot  be  produced  in  all  cases.  I  never  witnessed  it 
in  children  or  very  young  persons ;  it  is  most  common  in  males  of 
about  middle  life,  and  is  in  nowise  connected  with  any  previous 
disease  existing  in  the  respiratory  apparatus.    In  some  persons  the 


slightest  touch  of  the  floor  of  the  external  auditory  passage,  about 
midway  between  its  external  outlet  and  the  inferior  attachment  of 
the  membrana  tympani,  will  bring  on  violent  irritation  and  spas- 
modic action  in  the  larynx.  In  this  case  also  the  patient  will 
generally  tell  us,  upon  inquiry,  that  he  does  not  experience  pain ; 
but  that  the  moment  we  touch  this  very  sensitive  spot  he  feels  a 
tickling  sensation  in  his  throat,  which  immediately  increases  to 
the  feeling  one  has  when  **  a  bit  is  gone  astray."  What  the  ner- 
vous connexion  may  be  which  induces  this  has  not  been  fully  de- 
termined, but  the  fact  is  worthy  of  note.  The  different  degrees 
of  sensibility  of  the  several  parts  of  the  external  ear  are  worthy 
of  remark.  For  further  particulars  on  this  point,  and  also  as  re- 
regards  syringing,  see  the  section  on  Cerumen  in  Chapter  iv. 

The  effort  of  coughing,  sneezing,  blowing  the  nose,  and  de- 
glutition, in  causing  or  increasing  pain,  is  also  to  be  particularly 
attended  to,  if  we  suspect  inflammation  in  the  drum  or  the  Kusta- 
ohian  tube. 

There  are  two  methods  of  examining  the  ear,  on  which,  from 
their  frequency  in  this  country,  I  am  induced  to  make  some  re- 
marks, in  the  hope  of  putting  a  stop  to  practices  not  only  useless, 
but  in  some  cases  positively  injurious.  I  allude  to  the  common 
habit  of  syringing  indiscriminately,  and  also  of  probing  the 
ears,  without  proper  inspection  of  the  parts.  The  former  is  of 
daily  occurrence;  thus  a  patient  labouring  under  deafness,  or, 
what  perhaps  is  worse,  violent  pain  in  the  ear,  is  examined  either 
without  the  assistance  of  a  speculum,  or  by  means  of  some  oF  the 
old  divaricating  instruments,  most  probably  in  a  badly-lighted 
apartment, — at  all  events,  without  the  membrana  tympani  being 
brought  into  view,  a  dark  cavity  being  all  that  the  explorer  is 
able  to  perceive; — it  is  deemed  advisable  to  try  what  might 
come  out  by  squirting  hot  water  into  this  dark  passage  for  a 
quarter  of  an  hour  or  longer ;  but,  nothing  satisfactory  following 
this  operation,  the  diagnosis  that  there  is  no  wax  in  the  ear  is  ac- 
cordingly made.  Now,  there  may  be  a  collection  of  cerumen, 
which  may  not  be  got  rid  of  by  this  operation  ;  while,  if  the  cause 
of  the  pain  or  deafness  is  owing  to  an  inflammatory  condition  of 
the  auditory  canal  and  its  membranous  extremity,  a  decided  in- 


crease  of  the  symptoms  is  induced  by  this  useless  and  cruel  pro- 
ceeding :  and  I  have  frequently  seen  inflammation  produced  by 
unnecessarily  syringing  an  ear  where  no  wax  was  present. 

The  practice  of  exploring  the  ear  by  means  of  a  probe  I  can- 
not too  strongly  condemn,  and  yet  that  it  is  frequently  resorted  to 
surgeons  are  well  aware.  To  introduce  a  common  dressing  probe 
and  press  it  against  the  membrana  tympani,  without  having  that 
membrane  fairly  within  view,  and  without  a  speculum  being 
introduced,  but  merely  for  the  purpose  of  satisfying  the  examiner 
as  to  whether  the  membrane  is  perforate  or  not,  is,  I  think,  a 
most  unjustifiable  proceeding. 

The  degree  of  deafness  may  be  learned,  and  the  hearing  dis- 
tance measured,  by  holding  an  ordinary  watch  near  the  external 
meatus,  and  the  distance  at  which  the  tickings  can  be  accurately 
counted,  and  at  which  the  patient  is  conscious  of  an  interval  be- 
tween these  sounds,  should  be  recorded.  To  effect  this  properly, 
the  watch  should  be  approached  gradually  to  the  ear  till  it  gets 
within  the  hearing  point,  and  again  applied  directly  to  the  auricle, 
and  gradually  removed  to  some  distance.  Various  instruments, 
producing  a  ticking  sound  by  means  of  clockwork,  have  been  in- 
vented, by  Schmalz  and  others,  for  this  purpose,  but  the  watch  is 
quite  sufficient.  We  should  also  test  the  hearing  with  the  mouth 
open  as  well  as  shut ;  and  it  should  be  tried  both  before  and  after 
the  inflation  of  the  tympanum,  as  in  many  cases  that  act  will 
produce  a  very  material  difference  in  the  amount  of  hearing. 
The  watch  should  next  be  applied  both  behind  and  in  front  of 
the  auricle,  and  to  the  forehead,  and  also  placed  gently  between 
the  teeth  of  the  patient,  and  the  amount  of  hearing  thus  obtained 
likewise  noted.  It  is  absolutely  necessary,  if  we  wish  to  watch 
the  progress  of  a  case,  not  only  to  conduct  these  observations  with 
great  care,  but  also  to  take  a  written  note  of  the  *'  hearing  distance"* 
the  first  and  each  subsequent  time  we  see  the  patient.  By  this 
means  we  have  the  most  satisfactory  report  of  the  progress  of  the 
case,  both  for  ourselves  and  the  patient.  It  must  be  remembered 
that  there  is  almost  as  great  a  difiference  in  the  normal  hearing 
as  there  is  in  the  normal  seeing  distance,  even  among  persons 
who  have  never  laboured  under  any  disease  of  the  ear,  and  who 


are  not  at  all  conscious  of  any  defect  of  hearing.  The  degree  of 
hearing  with  a  watch  is  sometimes  deceptive ;  some  patients  who 
cannot  hear  a  watch,  or  even  a  clock,  will  hear  the  voice,  even  in 
a  low  tone ;  but  these  are  the  exceptions  to  the  rule.  Except  in 
cases  of  congenital  or  acquired  deaf-dumbness,  total  deafness  is  a 
rare  affection,  much  more  so  than  total  blindness ;  and  great  variety 
exists  with  respect  to  the  amount  of  hearing  lost,  and  how  the 
defect  is  described,  as,  for  instance,  hardness  of  hearing,  short 
hearing,  dulness  of  hearing,  &c. 

While  inquiring  into  the  amount  of  deafness,  and  the  circum- 
stances under  which  the  hearing  is  increased  or  diminished,  wc 
should  learn  whether  it  be  improved  or  not  when  the  patient  is 
exposed  to  loud  noises,  as  when  standing  in  a  mill,  walking 
through  a  crowded  street,  or  travelling  in  a  carriage  or  on  a  rail- 
way. We  should  also  inquire  whether  the  hearing  is  better  at  one 
time  of  the  day  than  another,  and  abo  whether  it  is  increased  or 
lessened  after  meals,  particularly  dinner. 

The  condition  of  the  throaty  the  arches  of  the  palate,  uvula, 
tonsils,  and  back  of  the  pharynx,  should  next  be  inquired  into, 
particularly  as  regards  the  state  of  the  mucous  membrane,  its 
colour,  turgescence,  or  degree  of  relaxation ;  likewise  the  state  of 
infiltration  of  the  submucous  tissue.  The  forefinger  should  then 
be  introduced  far  into  the  mouth,  and  its  point  made  to  press 
firmly  upwards  and  outwards  beyond  the  arch  of  the  palate,  op- 
posite the  mouth  of  the  Eustachian  tube,  and  notice  taken  of  the 
degree  of  pain  or  inconvenience  it  produces  there  and  in  the 
middle  ear.  We  should  also  carefully  examine  the  state  of  the 
membrane  of  the  nose,  for  which  purpose  the  little  instrument 
figured  at  page  55  will  be  found  useful. 

Something  may  be  gleaned  from  the  character  of  the  wice, 
as  few  instances  occur  of  intense  or  long-continued  deafness  with- 
out that  function  exhibiting  manifest  symptoms  of  the  defect  of 
hearing  to  a  greater  or  less  extent.  This  defect  does  not  seem  to 
be  produced  by  any  visible  alteration  in  the  parts  engaged  in  the 
mechanism  of  speech ;  it  often  takes  place  without  any  enlarge- 
ment of  the  tonsils,  elongation  of  the  uvula,  or  other  abnormal 
condition  of  the  throat,  larynx,  or  mouth.    There  is  a  peculiarity 


of  voice  and  speech  attendant  upon  deafness  approaching  some- 
what to  the  condition  and  character  of  articulation  which  the 
deaf-mute  educated  according  to  the  vocal  system  presents,  and 
which  once  heard  is  seldom  forgotten.  The  voice,  from  not  being 
perfectly  heard  by  the  patient  himself,  loses  its  sonorous  intonation, 
and  becomes  hoarse  and  inharmonious,  or  harsh  and  husky,  with  a 
metallic  twang.  In  time  the  patient  loses  the  power  of  modula- 
tion, and  often  appears  to  labour  under  that  defect,  commonly, 
though  incorrectly,  denominated  speaking  through  the  nose. 
Such  persons  generally  express  themselves  in  an  unnecessarily 
loud  tone;  they  speak  as  if  they  were  out  of  breath,  and  there 
is  a  sort  of  whistling  sound  in  the  speech  as  if  the  air  was  sipped 
in  through  the  mouth,  and  then  blown  out  through  the  nose ; 
and  in  the  advanced  stage,  particularly  if  the  disease  commenced 
in  youth,  the  utterance  becomes  indistinct.  Such  cases  are  gene- 
rally most  unfavourable,  and  I  make  it  a  rule  to  inform  the  pa- 
tient or  his  friends  of  my  suspicions,  even  before  I  institute  an  exa- 
mination, as  this  symptom  is  always  indicative  of  long-continued 
dulness  of  hearing.  If  the  patient  is  a  person  of  intelligence  we 
generally  find  that  he  anxiously  and  intently  watches  the  motions 
of  the  lips  of  the  person  by  whom  he  is  addressed,  in  order  to  aa* 
ttst  him  in  making  out  what  is  said.  I  know  several  persons  who 
can  understand  what  is  addressed  to  them  by  their  friends,  or 
those  to  whom  they  are  accustomed,  simply  by  observing  the  mo- 
tions of  the  lips.  The  works  describing  the  mode  of  teaching 
articulation  to  the  deaf  and  dumb  may  be  read  with  advantage  on 
the  subject. 

Persons  with  <^  musical  ears**  have  remarked  to  me  that  they 
first  became  aware  of  the  approach  of  deafness  by  not  being  able 
to  distinguish  one  octave  from  another;  yet  in  many  instances  the 
musical  ear  remains  unimpaired  though  general  hearing  is  much 

I  have  thus  described  the  routine  of  examination  that  will  be 
found  most  practically  useful.  Having  proceeded  thus  far,  we  may 
inquire  into  the  history  of  the  disease,  its  duration,  assigned  cause, 
the  pain,  noise,  the  probable  hereditary  nature  of  the  complaint, 
Ac.,  and  hear  the  subjective  symptoms,  in  the  usual  manner  in 



which  we  would  proceed  to  examine  any  other  medical  or  surgical 
case.  There  are,  however,  a  few  inquiries  which  should  be  par- 
ticularly made,  especially  as  to  .the  existence  of  iinnitua  aurium; 
and,  if  such  be  present,  what  are  the  peculiar  characters  of  it; 
how  many  kinds  of  noises  are  experienced ;  whether  they  are 
permanent  or  intermitting;  under  what  circumstances  they  are 
decreased  or  diminished ;  and,  above  all,  whether  the  patient  re- 
fers them  to  the  ears  or  to  the  interior  of  the  head ;  and  whether 
one  or  both  ears  are  equally  affected  by  them. 

The  value  of  tinnitus  as  a  diagnostic  has  been  greatly  over- 
rated. It  is  certainly  one  of  the  most  distressing  as  well  as  the 
most  frequent  symptoms  attendant  upon  affections  of  the  organs 
of  hearing,  but  its  cause  is  very  obscure  and  difficult  to  compre- 
hend, and  its  removal  still  more  difficult  to  achieve.  I  know  no 
symptom  concerning  which  a  more  cautious  prognosis  should  be 
given,  as  it  is  one  common  to  almost  all,  and  peculiar  to  none,  of 
the  diseases  of  the  ear.  Like  muscse  volitantes  in  the  eye,  it  may 
exist  as  an  isolated  symptom,  or  it  may  be  an  attendant  upon  se- 
veral aural  diseases.  It  is  often  caused  by  cerebral  disease ;  there- 
fore we  should  carefully  inquire  whether  it  is  felt  in  the  head  or 
in  one  or  both  ears ;  it  is  sometimes  an  accompaniment  of  derange- 
ment of  the  circulating,  digestive,  or  uterine  organs;  of  congestion 
of  the  brain,  haemorrhage,  hypochondria,  hysteria,  chlorosis,  anae- 
mia, typhus,  influenza,  or  simple  catarrh ;  of  closure  of  the  external 
meatus,  obstruction  of  the  Eustachian  tube,  and  impaction  of  the 
auditory  passage  with  wax ;  a  foreign  body,  or  even  a  hair  resting 
on  the  tympanal  membrane,  as  well  as  engorgement  of  the  lining 
membrane,  or  mucous  collections  in  the  tympanal  cavity,  and 
also  nervous  deafness,  will  all  produce  it.  Furthermore,  we  may 
remove  the  original  disease,  give  a  healthy  action  to  the  affected 
organ,  and  restore  its  function, — yet  will  the  noise  remain.  It  is 
always  most  felt  at  night  when  the  patient  lies  down  to  rest;  it  is 
least  experienced  in  the  open  air,  in  a  crowd,  or  when  travelling 
in  a  carriage.  It  seldom  or  never  co-exists  with  an  open  tym- 
panal membrane,  and,  therefore,  perforation  of  the  drum  has 
been  resorted  to,  and  occasionally  with  effect,  to  relieve  patients 
of  this  distressing  malady.     In  cases  of  complete  acquired  deaf- 


muteism  it  is  not  present.  So  great  is  the  discomfort  which  it 
gives,  that  persons  incurably  deaf,  and  who  are  quite  conscious 
of  the  impossibily  of  restoring  their  hearing,  will  still  apply  to  be 
relieved  from  this  haunting  and  most  annoying  symptom ;  and 
therefore  it  is,  that,  in  the  quack  advertisements,  we  always  read 
of  the  "promise  to  cure  ringings  and  noises  in  the  ears."  The 
peculiar  characters  of  the  tinnitus,  and  the  noises  to  which  it  is 
likened,  are  as  variable  as  sound  itself.  Do  these  characters  de- 
pend upon  the  cause  of  the  deafness,  or  the  portions  of  the  organs 
affected  ?  I  have  taken  some  pains  to  investigate  the  subject,  and 
I  believe  not.  They  are  no  more  dependent  upon  the  causes  of 
the  disease,  nor  the  structures  engaged,  than  the  peculiar  form 
which  ocular  spectra  and  motes  floating  before  the  eyes  are  conr 
tingent  upon  the  parts  concerned  in  ophthalmic  or  cerebral  dis- 
eases. No  one  has  yet  been  able  to  arrange  or  classify  the  pecu- 
liar description  of  muscae  contingent  upon  congestion,  amaurosis, 
choroid  disease,  cataract,  or  disease  of  the  brain  or  its  membranes; 
no  more  than  they  can  satisfactorily  account  for  both  muscse  and 
"  noises  in  the  ears"  in  cases  of  hasmorrhage. 

I  think  the  descriptions  which  patients  give  of  the  noise  which 
they  experience  depend,  to  a  certain  degree,  upon  their  fancy,  their 
graphic  powers  of  explanation,  and  not  unfrequently  upon  their 
rank  of  life,  or  the  position  in  which  they  have  been  placed,  and 
the  sounds  with  which  they  are  most  familiar:  thus,  persons  from 
the  country  or  rural  districts  draw  their  similitudes  from  the  objects 
and  noises  by  which  they  have  been  surrounded,  as  the  falling 
and  rushing  of  water,  the  singing  of  birds,  buzzing  of  bees,  and 
the  waving  or  rustling  of  trees ;  while,  on  the  other  hand,  persons 
living  in  towns,  or  in  the  vicinity  of  machinery  or  manufactureSi 
say  that  they  hear  the  rolling  of  carriages,  hammerings,  and  the 
various  noises  caused  by  steam-engines.  Servants  almost  inva- 
riably add  to  their  other  complaints,  that  they  suffer  from  "  the 
ringing  of  bells"  in  their  ears ;  while  in  this  country,  old  women 
much  given  to  tea-drinking  sum  up  the  category  of  their  ail- 
ments by  saying,  that  "  all  the  kettles  in  Ireland  are  boiling  in 
their  ears."    The  tidal  sound,  or  that  which  we  can  produce  by 



holding  a  conch-shell  to  the  ear,  is,  however,  what  is  most  fre- 
quently complained  of.  Sometimes  the  tinnitus  exists  as  an  iso- 
lated symptom ;  but  in  several  such  cases  I  have  remarked,  that 
sooner  or  later  either  aural  or  cerebral  disease  manifested  itself. 
Removing  the  cause  and  curing  the  deafness  will  often,  but  not 
always,  relieve  the  patient  of  the  noise. 

The  causes  of  tinnitus — for  they  must  be  many — are  never 
likely  to  be  fully  explained ;  and  morbid  anatomy  holds  out  but 
little  hope  of  clearing  up  the  mystery  attending  the  production  of 
noises  in  either  the  ears  or  head.  From  its  not  being  present 
where  the  membrana  tympani  has  been  in  whole  or  in  part  re- 
moved, and  that  hearing  is  not  quite  destroyed,  and  from  its  ces- 
sation after  artificial  perforation  on  the  one  hand ;  and,  as  we  have 
all  experienced  its  occasional  presence  in  influenza,  sore  throat,  or 
simple  catarrh,  until  by  pressing  air  through  the  Eustachian  tube 
into  the  tympanal  cavity,  we  instantaneously  get  rid  of  it, — on  the 
other ;  I  am  firmly  of  opinion  that  one  cause  of  tinnitus  is  a  non* 
vibratability  of  the  membrana  tympani.  All  cases  of  closure  of 
the  Eustachian  tube,  of  collapse  of  the  membrana  tympani,  as  well 
as,  in  most  instances,  of  accumulations  in  the  middle  ear,  are 
attended  by  this  symptom.  Kramer  formerly  thought  that  his 
so-called  nervous  deafness  might  be  divided  into  the  erethetic,  or 
that  attended  with  tinnitus — generally  incurable — and  the  torpid, 
or  that  without  tinnitus,  said  to  be  relieved  by  fumigation  I  He 
has,  however,  subsequently  relinquished  this  fanciful  and  hypo- 
thetical division.  Laennec  considered  tinnitus  as  an  acoustic  illu- 
sion ;  but  buzzing  in  the  ear  might,  he  thought,  depend  on  spas- 
modic contraction  of  the  muscles  of  the  ossicles.  This  latter 
theory,  though  unsustained  by  any  fact,  serves  to  support  the 
hypothesis  of  the  want  of  vibrating  power  in  the  membrana  tym- 
pani being  one  cause  of  tinnitus;  possibly  a  similar  state  of  the 
membrane  of  the  fenestra  rotunda  may  be  another. 

Physicians  are  too  much  in  the  habit  of  treating  patients  for 
this  symptom  alone,  without  having  made  a  careful  examination 
of  the  ears.  I  have  seen  persons  who  had  been  subjected  to  a  se- 
vere course  of  treatment,  consisting  of  cupping  and  leeching,  low 
diet,  blistering  the  nape  of  the  neck,  purgation,  salivation,  or  the 


administration  of  blue  pill  and  James's  powder,  for  noises  in  the 
ears  and  head,  until  it  was  eventually  discovered  that  all  their 
symptoms  proceeded  from  a  comparatively  thin  cake  of  hardened 
wax  pressing  on  the  drum  of  the  ear. 

Inquiries  as  to  the  general  health  of  the  patient,  the  due  per- 
formance of  all  the  functions,  and  the  endeavour  to  ascertain  how 
much  of  the  disease  is  purely  local,  or  dependent  upon  some  con- 
stitutional affection,  will,  no  doubt,  be  made  by  every  educated 
physician  or  surgeon,  so  that  it  is  unnecessary  here  to  call  special 
attention  to  these  circumstances. 

By  the  foregoing  method  of  examination  and  observation  of 
the  physical  signs,  and  an  attention  to  the  rules  which  I  have  en- 
deavoured to  lay  down,  we  ought  in  almost  every  case  be  able  to 
form  a  tolerably  accurate  diagnosis. 

As  much  ignorance  prevails  with  respect  to  the  mode  of  ap- 
plying even  the  ordinary  remedies  employed  in  aural  affections, 
a  few  remarks  thereon  may  not  be  out  of  place,  before  entering 
upon  a  description  of  the  cases  to  which  they  are  applicable.  As 
most  of  the  diseases  of  the  organs  of  hearing  are  originally  of  an 
inflammatory  character,  depletion  is  strictly  enjoined;  I  have, 
however,  seldom  found  it  necessary  to  resort  to  general  bleeding ; 
but  local  depletion  is  imperatively  required,  either  by  cupping  or 
by  leeches.  The  former  method  is  not  easily  managed  so  near 
the  part  affected  as  to  be  of  much  service ;  but  in  cases  of  very 
severe  otitis,  it  may  be  had  recourse  to,  and  a  dexterous  cupper 
will  with  a  small  instrument  take  several  ounces  of  blood  from 
the  soft  parts  immediately  behind  and  beneath  the  mastoid  pro- 
cess; and  if  the  head  be  much  engaged,  blood  may  also  be  ab- 
stracted by  the  same  means  from  the  nape  of  the  neck.  Leeches 
are,  however,  the  most  effectual  means  of  abstracting  blood  and 
relieving  pain  in  all  such  cases ;  but  they  should  not  be  applied 
in  the  manner  heretofore  employed  behind  the  mastoid  process: 
to  be  of  service  they  must  be  attached  with  a  small  bevil-mouthed 
leech-glass  immediately  around  and  within  the  edge  of  the  exter- 
nal meatus,  in  the  fossa  behind  the  tragus,  and,  if  necessary,  in 
front  of  that  prominence,  in  the  hollow  formed  by  depressing  the 
jaw.  From  four  to  six  leeches  may  be  readily  attached  round  the 

86  LBECHnro. 

meatus,  and  in  this  situation  they  will  produce  more  immediate 
and  permanent  relief  than  three  times  the  nnmber  affixed  behind 
the  auricle.  The  application  in  front  of  the  tragus  is  also  very 
much  more  effectual  than  upon  the  mastoid  region.  When,  how- 
ever, the  latter  locality  becomes  itself  the  seat  of  inflammatory 
action,  they  should  also  be  applied  freely  all  over  it.  Where  we 
have  already  recently  applied  leeches  in  the  two  first-mentioned 
places,  and  that  the  parts  have  thereby  become  swollen  and  ir- 
ritated, the  next  most  advantageous  position  is  beneath  the  lobe 
of  the  auricle,  behind  the  ramus  of  the  jaw.  I  do  not  know  any 
painful  affection  in  which  leeches  applied  in  the  manner  directed 
produce  the  same  amount  of  immediate  relief,  as  in  disease  of 
the  ear.  They  should  be  had  recourse  to  again  and  again,  even 
upon  the  same  day,  and  applied  in  numbers,  to  relieve  paroxysms 
of  pain,  as  well  as  to  lessen  the  degree  of  redness  and  vascularity 
observable  in  the  inflamed  parts. 

Unless  in  cases  of  violent  otitis,  heretofore  leeches  were  sel- 
dom used  to  relieve  aural  diseases,  because  the  practitioner, 
not  being  acquainted  with  the  nature  or  seat  of  the  majority  of 
these  affections,  and  not  possessing  the  means  or  knowledge  ca- 
pable of  effecting  a  proper  inspection  of  the  parts  engaged, 
seldom  made  an  accurate  diagnosis.  He  worked  in  the  dark,  and 
prescribed  at  random,  more  frequently  than  when  treating  any 
other  class  of  diseases,  no  matter  how  obscure;  and  hence  the 
opprobrious  epithets  which  the  public,  and  even  many  of  the 
profession,  applied  to  the  treatment  of  diseases  of  the  ear.  Such 
observations  were,  however,  just  as  applicable  to  the  treatment  of 
diseases  of  the  uterus  and  vagina  until  the  introduction  of  the 
speculum  into  modern  practice.  As  the  space  to  which  leeches 
can  be  applied  is  limited,  and  as  it  is  often  a  tedious  and  trouble- 
some operation,  it  requires  some  care  and  dexterity  in  its  manage- 
ment. I  generally  mark  the  places  where  they  may  be  applied 
with  spots  of  ink,  in  order  that  the  apothecary  may  not  make  any 
mistake ;  for,  if  this  is  not  done,  we  sometimes  find  that  the 
leeches  have  been  allowed  to  attach  themselves  to  the  cavity  of 
the  concha,  or  other  places  on  the  auricle,  where  they  are  of  no 
use,  and  often  give  rise  to  much  irritation,  oedema,  and  even  ery- 


sipelas.  The  external  meatus  should  first  be  filled  with  a  bit  of 
cotton  wool,  to  a  level  with  the  external  aperture,  not  so  much 
for  the  purpose  of  preventing  the  leeches  going  in  too  far,  as  to 
exclude  the  blood,  which  is  very  likely  to  flow  back  and  accu- 
mulate at  the  bottom  of  the  meatus  auditorius  extemus,  coagulat- 
ing and  crusting  over  the  surface  of  the  tympanal  membranOi 
thereby  causing  much  annoyance  to  the  patient,  and  even  an  ag« 
gravation  of  his  symptoms.  The  posterior  lip  of  the  external 
aperture  afibrds  the  largest  and  most  convenient  surface  for  the  ap- 
plication of  leeches,  and  in  an  adult,  three  may  always  be  attached 
thereto  with  facility.  The  anterior  lip,  being  more  concealed  and 
slightly  concave,  cannot  so  well  be  got  at,  yet  two  may  generally 
be  applied  there.  The  next  best  part  to  which  to  apply  them  is 
the  depression  in  front  of  the  tragus,  immediately  below  the  infe- 
rior root  of  the  zygoma,  where  in  aural  inflammations  the  patient 
is  so  frequently  susceptible  of  pain  upon  the  least  pressure,  and 
there,  six  or  eight  may  be  applied  if  necessary. 

As  leech-bites  on  any  of  those  places  which  I  have  mentioned 
continue  to  bleed  freely  for  a  long  time,  the  person  employed  to 
apply  the  leeches  should  be  directed  to  stop  them  as  soon  as  the 
proper  quantity  of  blood  has  been  removed,  either  by  the  applica- 
tion of  lunar  caustic,  or  any  of  the  most  approved  means  for  this 
purpose ;  but  it  is  necessary  that  we  should  be  aware  of  the  fact, 
that  the  haemorrhage  from  leech-bites  on  these  parts  is  more 
ikely  to  continue  than  elsewhere.     The  leech-bites  do  not  cause 
xtravasation  and  blackening  of  the  auricle  as  they  so  frequently 
0  the  parts  about  the  eye ;  but  they  often  give  rise  to  erysipelatous 
flammation,  and  therefore  in  all  such  cases  the  idiosyncrasy  of 
e  patient  in  this  matter  should  be  previously  inquired  into.     I 
ow  a  gentleman  with  a  remarkably  dry  skin,  who  labours  un* 
*  chronic  inflammation  of  the  membrana  tympani  and  the  mu- 
8  lining  of  the  middle  ear,  who  is  so  susceptible  in  this  respect 
.  the  application  of  a  single  leech  will  invariably  produce  ery- 
lasofthe  side  of  the  head  and  face.     The  cotton  with  which 
vuditory  passage  is  stufled,  and  the  external  portion  of  which 
ys  becomes  saturated  with  the  blood,  should  not  be  removed 
the  oozing  from  the  leech-bites  has  quite  ceased. 


With  respect  to  counter-irritation : — ^in  acute  cases,  common  fly 
blisters  are  the  most  convenient  and  effectual  method ;  but  as  the 
space  uncovered  by  hair  over  which  they  can  be  applied  behind 
the  auricle  is  limited,  they  should  not  have  the  usual  adhesive 
margin  on  the  inner  concave  edge,  and  they  should  be  spread  on 
fine  leather,  that  they  may  fit  closely  over  the  irregular  surface  to 
which  they  are  applied.  If  it  is  desirable  to  keep  the  blister  open, 
or  to  establish  an  issue,  it  can  easily  be  effected  by  removing  the 
cuticle  and  dressing  the  raw  surface  with  Albespeyrre*s  plaster,  the 
most  convenient  spot  for  which  is  immediately  behind  the  lobe, 
and  beneath  the  mastoid  protuberance.  It  is,  however,  especially 
in  the  male  sex,  difficult  to  retain  such  means  in  that  locality  with- 
out a  bandage. 

In  old  chronic  cases,  where  the  disease  is  of  long  standing, 
and  there  is  much  thickening  of  the  membrana  tympani,  I  have 
found  that  the  pustules  produced  by  the  application  of  tartar 
emetic  ointment  are  the  most  effectual  method.  A  small  quantity 
of  the  ointment  should  be  rubbed  once  or  twice  a  day  to  all  that 
part  of  the  mastoid  region  which  is  not  covered  by  hair, — care 
being  taken  not  to  let  the  ointment  spread  over  the  back  of  the 
auricle,  where  it  would  produce  very  angry  and  irritable  sores, — 
until  a  copious  eruption  is  produced.  A  bit  of  soft;  linen  should 
be  applied  between  the  auricle  and  the  surface  submitted  to  the 
action  of  the  remedy.  As  soon  as  the  pustules  are  fully  deve- 
loped the  application  should  be  discontinued,  and  the  part  al- 
lowed to  heal  perfectly  before  it  is  resumed.  To  be  effectual, 
however,  this  remedy  must  be  continued  for  several  weeks,  or 
even  months.  As  it  is  not  always  possible  to  measure  or  control 
its  action,  a  poultice  should  be  applied  occasionally  when  the  pus- 
tules spread,  or  seem  inclined  to  coalesce. 

The  usual  rubefacient  and  vesicating  liniments  must  be  used 
with  caution  when  applied  to  the  mastoid  region,  as  their  action 
is  very  apt  to  spread  over  the  back  of  the  auricle,  and  cause  con* 
siderable  swelling  and  irritation  thereof  I  have  on  several  occa- 
sions seen  the  eruption  caused  by  croton  oil  extend  from  the  mas- 
toid region  not  only  over  the  external  ear,  but  to  the  side  of  the 
face,  and  produce  oedema,  redness,  and  intense  itching  of  the  eye- 


lids.  Where  there  is  much  neuralgic  pain  complained  of,  ex- 
tending from  the  ear  over  the  side  and  back  of  the  head,  I  have 
found  the  compound  camphor  liniment,  with  extract  of  bella- 
donna, one  of  the  most  useful  applications ;  but  in  this  preparation 
care  should  be  taken  to  rub  the  belladonna  first  with  a  little  wa- 
ter in  a  mortar,  otherwise  it  will  not  mix  with  the  liniment.  In 
children  and  young  persons  the  strong  tincture  of  iodine,  contain- 
ing some  iodide  of  potassium,  is  a  very  useful  remedy,  and  pro- 
bably acts  specifically  as  well  as  a  stimulant ;  it  should  be  applied 
with  a  camel-hair  pencil  daily,  or  every  second  day,  unless  the 
parts  begin  to  vesicate  or  the  cuticle  to  peel  ofif,  when  the  applica- 
tion should  be  discontinued  for  a  few  days.  The  use  of  iodine, 
however,  by  the  edermic  method  is  only  of  value  by  being  long  per- 
sisted in.  Indeed  the  same  may  be  said  of  most  irritants, — to  be 
effective  they  must  be  continued  for  a  great  length  of  time,  long 
before  the  expiration  of  which,  in  many  cases,  both  the  patient 
and  the  practitioner  are  tired  of  each  other. 

The  application  of  lieat  and  moisture  is  particularly  grateful ; 
steaming  the  ear  by  holding  it  over  the  vapour  of  some  very  hot 
water  placed  at  the  bottom  of  a  long,  narrow  vessel,  medicated 
with  hyoscyamus,  opium,  belladonna,  or  with  the  ordinary  decoc- 
tion of  marsh-mallows,  camomile,  or  poppy-heads,  gives  great  com- 
fort The  Russians  employ  a  peculiar  apparatus  for  relieving 
pain  in  the  ear,  consisting  of  a  funnel-shaped  roll  of  linen,  the 
small  end  of  which  is  applied  to  the  meatus,  while  the  large  end, 
in  which  various  balsamic  substances  are  placed  and  set  fire  to, 
is  allowed  to  burn  down  slowly  like  a  moxa.  A  warm  linseed- 
meal  poultice,  renewed  every  two  or  three  hours,  gives  great  relief. 
Stupes  and  fomentations  are  not  as  efficacious  in  aural  as  in  oph- 
thalmic inflammations. 

Under  no  circumstances  should  wo  pour  any  stimulating  or 
sedative  liquors  into  the  ear.  From  the  firequency  of  this  most 
unjustifiable  practice  in  this  country,  I  feel  I  cannot  too  strongly 
deprecate  it.  If  there  is  one  substance  more  irritating  than  ano- 
ther in  the  Pharmacopoeia,  it  is  poured,  secundum  artem^  into  the 
ear,  to  relieve  pain,  or  cure  dea&ess,  to  lessen  or  to  increase  the 
secreUon  of  wax  I    This  practice  is  often  the  cause  of  myringitis. 


Why  are  not  these  essential  oils,  stimulating  liniments,  this  tur- 
pentine, creasote,  tincture  of  cantharides,  oil  of  origanum,  &c., 
poured  into  the  eye,  or  injected  into  the  urethra,  in  cases  of  in- 
flammation of  these  parts  ?  Why  do  not  surgeons  prescribe  a 
roasted  onion,  or  a  boiled  fig,  for  inflammations  of  other  parts  as 
well  as  the  ear? 

I  have  no  faith  in  either  electro-magnetism,  galvanism,  or 
electricity,  in  relieving  deafness.  I  never  knew  a  case  which  had 
proved  unamenable  to  other  treatment  cured  by  any  of  these 
means.  True  it  is  we  read  in  the  periodicals  from  year  to  year 
of  cures  effected  by  such  agents,  but  for  the  most  part  they  are 
unauthenticated,  and  in  all,  there  is  in  the  description  of  symp- 
toms and  the  diagnosis  a  manifest  want  of  knowledge  on  the  sub- 
ject of  aural  medicine  and  surgery.  How  would  the  profession 
receive  an  account  of  a  "  cure  of  blindness  by  electro-galvanism," 
without  being  informed  what  had  been  the  cause  of  such  loss  of 
sight  ?  However,  as  I  believe  the  great  mass  of  aural  diseases  are 
the  products  of  inflammation  in  some  form  or  other,  it  is  obvious 
that  such  agents  can  effect  little  for  their  removal.  Even  sup- 
posing the  auditory  nerve  to  be  the  seat  of  the  disease,  and  that  a 
true  cophosis,  the  analogue  to  amaurosis,  is  present,  it  may  be 
asked,  how  few  uncomplicated  cases  of  the  latter,  of  simple  func- 
tional impairment  or  insensibility  of  the  retina  or  optic  nerve, 
without  any  cerebral  lesion,  do  we  meet  with  ?  and  how  still 
fewer  do  we  remember  being  cured  or  relieved  by  electricity  or 
galvanism  ?  It  is  therefore  unnecessary  to  describe  the  various 
ingenious  machines  which  have  been  invented,  and  are  described 
in  books,  for  applying  these  means  to  the  Eustachian  tube,  and 
the  external  surface  of  the  tympanal  membrane. 

Mercury  is  the  medicine  which  of  all  others  acts  most  bene- 
ficially in  diseases  of  the  ears,  simply  on  account  of  its  specific 
efficacy  in  arresting  or  controlling  inflammation  or  removing 
its  products.  But  as  there  are  a  variety  of  aural  affections  to 
which  it  is  applicable,  so  are  there  a  variety  of  modes  of  adminis- 
tering this  powerful  mineral,  and  a  diversity  of  preparations,  each 
specially  apposite  to  the  particular  stage  of  disease,  the  class  of 
symptoms,  or  the  peculiar  habits  and  constitution  of  the  patient. 


A  well-educated  surgeon,  experienced  in  the  administration  of 
mercury,  and  with  general  and  enlarged  views  both  as  to  the  ac- 
tion of  medicine  and  disease,  will,  no  doubt,  suit  the  remedy  to 
the  particular  case ;  but  as  a  rule  I  may  remark,  that  the  modes 
of  exhibiting  it  in  ocular  affections  will  serve  as  a  safe  guide  for 
giving  it  in  diseases  of  the  organ  of  hearing.  In  the  more  vio- 
lent inflammations  of  the  fibrous  structure  of  the  membrana  tym- 
pani,  the  periosteal  lining  of  the  cavity  of  the  tympanum,  the  Eusta- 
chian tube,  or  the  deeper  portion  of  the  external  meatus,  and  also 
the  inflammations  of  the  internal  ear,  when  such  can  be  diagnosed, 
as  well  as  the  specific  inflammations  of  a  rheumatic  or  syphilitic 
character,  where  actual  ptyalism  is  indicated,  we  must  introduce 
it  quickly,  and  in  such  doses  as  will  bring  the  system  under  its 
influence  at  once,  just  as  we  would  in  inflammations  of  analo- 
gous tissues  in  the  eye,  the  envelopes  of  bones,  or  the  membranes 
investing  the  joints  or  any  of  the  great  cavities  of  the  body.  In 
such  cases  small  and  frequently  repeated  doses  of  blue  pill  and  calo- 
mel, with  opium,  will  most  speedily  produce  the  desired  efiect, 
provided  the  well-known  rules  for  the  administration  of  mercury 
are  attended  to.  I  do  not  think,  however,  that  students  attend 
sufficiently  to  the  symptoms  and  appearances  produced  by  mer- 
cury on  the  mouth.  Among  the  lower  orders,  or  with  hospital 
patients,  the  over-action  of  mercury  upon  his  patient  seldom  gives 
the  practitioner  much  uneasiness ;  but  in  private  practice  it  is  very 
different.  There  is  a  general  horror  of  mercury  among  the  middle 
and  upper  ranks ;  and  the  prejudices  and  superstitions  which  exist 
on  the  subject,  with  respect  to  the  mischief  it  does  to  the  constitu- 
tion, and  the  difficulty  of  **  getting  it  out  of  the  boncs,^  are  still  as 
rife  among  some  classes  as  when  a  distinguished  and  titled  senator 
swore,  at  the  trial  of  St.  John  Long,  that  he  saw  the  mercury  which 
had  been  taken  many  years  before  appear  in  globules  of  pure  quick- 
silver upon  the  forehead  of  a  nobleman,  drawn  forth  by  the  effi- 
cacy of  the  sponge  and  liniment  of  the  redoubted  curer  of  con- 
sumption !  The  effect  of  mercury  upon  the  constitution,  as  well 
as  upon  disease,  is  most  variable.  With  some  the  slightest  quan- 
tity will,  unless  carefully  watched,  produce  salivation ;  while  other 
persons  seem  totally  unsusceptible  of  its  influence.     The  abuse, 


however,  which  one  comes  in  for  in  practice,  because  a  patient  has 
suddenly  got  a  very  sore  mouth,  should  be  borne  with  philosophic 
indifference ;  as  although  the  effect  is  in  excess,  the  desired  result 
has  been  obtained.  Some  ladies,  however,  will  fret  about  the  da- 
mage likely  to  be  done  to  their  teeth,  more  than  they  did  for  the 
disease  for  which  the  mercury  was  given ;  and  many  patients, 
who  greedily  learn  all  the  symptoms  of  its  action,  will  complain 
of  sore  mouths,  spongy  gums,  aching  teeth,  &c.,  when,  in  reality, 
it  is  impossible  to  affect  them. 

Few  of  us  now  witness  what  mercury  can  do  when  allowed 
ts  full  swing,  or  when  pressed  to  the  extent  which  it  was  some 
twenty  or  thirty  years  ago.  Very  few  of  us  have  now  an  oppor- 
tunity, I  am  happy  to  say,  of  witnessing  many  cases  of  mercurial 
erythema,  or  the  prostration  of  ery thismus,  or  seeing  every  tooth 
in  a  patient's  head  shaking,  and  streams  of  saliva  pouring  from  his 
mouth,  from  the  long-continued  use  of  the  mineral, — when  the 
wards  of  an  hospital  were,  from  the  quantity  of  mercury  used,  both 
internally  and  externally , by  pill-taking,  skin-rubbing,  plasters,  and 
fumigation,  rendered  mercurial  baths,  in  which  the  vapour  of  fetid 
breaths  contended  with  the  stench  of  sloughing  ulcers,  and  the 
effluvia  resulting  from  mercurial  diarrhoea.  Such  times  and  scenes 
have  passed,  and  the  public  and  the  profession  have  reason  to  re- 
joice thereat.  Practitioners  are  now  satisfied  with  the  mild  ex- 
hibition of  mercury,  and  deem  it  more  prudent  to  keep  up  a 
gentle  action  for  some  time  than  to  allow  profuse  salivation  to 
occur.  Yet,  notwithstanding  all  this,  cases  will  happen  the  re- 
verse of  the  unsusceptible,  in  which  the  mineral  acts  suddenly 
and  violently,  and  its  effects  are  scarcely  within  control.  This 
will  occur  occasionally  in  peculiar  constitutions,  where  there  is 
a  special  idiosyncrasy.  Profuse  salivation  raj^idly  sets  in,  the 
glands  of  the  neck  enlarge,  the  mucous  membrane  of  the  throat 
and  inside  of  the  mouth  runs  rapidly  into  ulceration,  and  the 
tongue  swells  to  an  alarming  extent,  so  as  to  resemble  a  case  of 
glossitis,  but  it  is  white,  slimy,  and  looks  like  a  piece  of  mace- 
rated liver,  and  it  not  uncommonly  protrudes  between  the  teeth. 
The  most  alarming  symptoms  occasionally  follow,  and  in  one  in- 
stance death  occiurred,  in  this  city,  some  years  ago,  from  swelling 


of  the  tongue  in  the  manner  which  I  described,  and  as  the  result 
of  sudden  and  uncontrollable  mercurial  action.  Sometimes  the 
cheeks  and  other  parts  of  the  face  swell  to  a  great  extent.  It  is 
scarcely  necessary  to  state,  that  deglutition  and  respiration  must 
be  considerably  impaired  under  such  a  state  of  things.  Among 
the  remarkable  effects  of  mercury  which  I  have  seen,  I  may  men- 
tion the  instance  of  a  lady  who  once  consulted  me  on  account  of 
.profuse  salivation  which  had  continued  for  five  years. 

Now  it  is,  as  I  already  observed,  because  I  do  not  think  stu- 
dents attend  sufficiently  to  the  appearances  which  mercury  pre- 
sents in  the  mouth,  and  also  because  cases  of  excessive  mercurial 
action  must  occasionally  occur  in  large  public  institutions,  where 
it  is  absolutely  necessary  to  give  mercury  to  external  patients, 
many  of  whom  are  either  careless  and  indifferent  about  them- 
selves, or  are,  from  their  domestic  circumstances,  more  than  ordi- 
narily exposed  to  the  vicissitudes  of  the  weather,  that  I  wish  par- 
ticularly to  draw  attention  to  the  earlier  and  milder  symptoms 
of  mercurial  action.  The  fetor  of  the  breath  is  a  variable  sign, 
although  when  present  it  is  an  unfailing  indication ;  but  it  is  sel- 
dom commensurate  with  the  amount  of  mercurial  action.  Some- 
times  the  breath  is  naturally  heavy,  or  even  fetid,  and  then  it  is 
difficult  to  distinguish  the  one  from  the  other.  There  is  a  pe- 
culiar  heavy  breath  belonging  to  strumous  patients,  which  it  is 
difficult  to  describe,  but  which,  once  perceived,  is  easily  recog- 
nised ever  after.  I  may  here  mention,  that  I  do  not  remember  a 
single  instance  in  which,  for  any  cause,  mercurial  action  was  fully 
produced  in  a  person  possessing  naturally  what  is  termed  *'bad 
breath,**  that  that  most  unpleasant  affection  was  not  removed  by 
it.  There  is  often  some  swelling  of  the  gum  behind  the  last 
molar  tooth  of  the  lower  jaw ;  this  I  look  upon  as  an  almost  in- 
variable symptom,  and  sometimes  it  is  the  only  one  which  can  be 
produced.  The  mucous  membrane  between  the  tooth  and  the 
angle  of  the  jaw  swells  and  overlaps  the  tooth,  rendering  masti- 
cation very  unpleasant,  and  giving  rise  to  the  disagreeable  feeling 
which  one  experiences  when  cutting  a  wise  tooth.  We  should 
always  look  into  the  mouth,  as  well  as  examine  the  gums  beneath 
the  front  teeth,  or  smell  the  breath,  where  we  wish  to  assure  our- 


eelves  as  to  the  progress  of  the  medicine.  Another  early  symp- 
tom is,  a  slight  discoloration  of  the  mucous  membrane  upon  the 
inside  of  the  cheeks:  it  loses  its  fresh,  red  colour,  and  becomes 
whitish,  particularly  opposite  the  crowns  of  the  lower  teeth,  the 
indentures  of  which  soon  manifest  themselves  upon  it,  and  in  a 
short  time,  if  the  medicine  be  not  lessened,  ulceration  will  ensue 
in  that  locality.  One  of  the  first  places,  however,  where  any 
breach  of  surface  occurs  upon  the  mucous  membrane  is  imme-. 
diatcly  below  the  red  border  of  the  under  lip,  opposite  the  junc- 
tion of  the  gum  with  the  lower  incisors.  About  the  same  time 
the  tongue  becomes  slightly  swollen,  and  its  edge  deeply  indented 
with  the  lower  front  teeth ;  it  is  of  a  greyish-white  colour,  and 
covered  with  slimy  saliva.  AH  the  glandular  apparatus  within 
the  mouth  is  then  excited  to  excessive  action ;  the  papillae  of  the 
sublingual  ducts  become  swollen  and  erect,  and  the  ulcerations 
upon  the  inside  of  the  lower  lip  and  opposite  the  buccal  glands 
upon  the  cheeks  present  the  appearance  of  aphthous  sores,  greyish 
in  the  centre,  with  a  slight  straw-coloured  margin ;  and  saliva, 
mixed  with  mucus,  pours  from  every  possible  outlet.  As,  how- 
ever, these  observations  are  not  intended  as  a  dissertation  on  the 
pharmaceutical  preparations  or  therapeutic  effects  of  mercury, 
but  are  here  put  forward  in  order  to  explain  its  applicability  to 
certain  diseases  of  the  ear,  it  would  be  out  of  place  to  enter  into 
an  exposition  of  the  means  best  calculated  to  correct  its  illegiti* 
mate  action  either  upon  the  mouth  or  gastro-intcstinal  membrane. 

In  the  more  chronic  or  subacute  forms  of  aural  disease — often 
where  the  mucous  membrane  is  extensively  engaged,  or  when 
congestion,  more  than  inflammation,  is  present — mercury  is  a 
valuable  remedy,  either  as  an  alterative  or  to  keep  up  sustained 
but  gentle  action  on  the  mouth ;  and  in  such  cases  the  milder 
preparations,  such  as  the  hydrargyrum  cum  creta,  in  combination 
with  cicuta,  will  be  found  advantageous. 

The  third,  and  perhaps  the  most  efficacious  form,  in  which 
mercury  may  be  used,  is  that  of  the  bichloride,  still  commonly 
known  in  this  country  as  the  oxymuriate,  one  of  the  most  va- 
luable medicines  of  the  entire  Pharmacopoeia.  A  treatise  might 
be  written  on  the  virtues  of  this  remedy,  and  the  vast  field  of  dis- 


ease  over  which  it  exercises  a  sanative  influence.  Combined  with 
Peruvian  bark — which  the  chemists  say  is  incompatible,  but  the 
product  of  the  decomposition  said  to  be  produced  by  which,  may 
be  the  very  substance  which  acts  most  beneficially — it  is  almost  a 
panacea  for  most  of  the  strumous  inflammations  in  children  and 
young  people ;  and  its  power  in  controlling  scrofulous  ophthalmia, 
comeitis,  and  iritis,  &c.,  extends  equally  to  the  cure  of  kindred 
affections  in  the  ear.  It  is  the  best  remedy  I  know  of  for  inducing 
absorption  of  lymphy  deposits  in  the  membrana  tympani,  and 
general  thickening  and  opacity  of  that  structure,  as  well  as  very  old 
cases  of  chronic  inflammation  of  the  membrane  of  the  cavitas 
tympani.  It  is,  moreover,  when  properly  administered,  one  of  the 
safest  as  well  as  the  surest  preparations  of  mercury :  it  may  be 
taken  for  a  great  length  of  time ;  it  seldom  interferes  with  the  or- 
dinary occupations  or  amusements  of  the  individual;  it  leaves  no 
ill  effects;  it  rarely  induces  ptyalism;  and  patients  improve  in 
health,  and  absolutely  grow  fat  while  using  it.*  It  may  be  given 
alone,  either  in  pill  or  dissolved  in  nitrous  ether,  proof  spirits,  or 
some  of  the  tinctures,  such  as  cascarilla,  but  it  is  much  more  solu- 
ble in  distilled  water  than  is  generally  known ;  it  may  be  com- 
bined with  the  muriated  tincture  of  iron  with  good  effect,  or  with 
some  of  the  preparations  ofsarsaparilla;  but  bark — either  the  tinc- 
ture, syrup,  or  decoction — ^is  of  all  others  the  medicine  best  suited 
for  its  administration.  Our  Dublin  preparation  of  the  syrup  is, 
particularly  for  children,  a  good  vehicle  for  it,  provided  the  mi- 
neral is  first  dissolved  in  a  little  distilled  water.  Oxy muriate  of 
mercury  and  bark  sometimes  disagree,  producing,  shortly  after  be- 
ing taken,  pain  in  the  stomach,  tenesmus,  griping,  and  even  diar- 
rhoea; in  such  cases  it  will  generally  be  found  that  it  was  taken 
before  breakfast  or  on  an  empty  stomach ;  it  should  therefore  be 
administered  an  hour  or  two  after  meals.  But  when  it  disagrees, 
even  with  such  precautions,  a  separation  of  the  constituents  will 
obviate  the  unpleasant  effects :  thus  the  mercury  may  be  taken  an 
hour  or  two  before  or  after  the  bark.  From  the  sixteenth  to  the 
eighteenth,  or  even  a  quarter  of  a  grain,  may  be  taken  three  times 

*  I  undentand  that  the  bichloride  of  merctuy,  in  large  doses,  is  used  to  fatten  and 
Impioye  the  condition  of  horses  in  the  West  Indies. 

96  MBaCUBT. 

a  day,  according  to  the  circumstances  of  the  case,  for  weeks  and 
even  months  together,  with,  however,  short  intervals  occasionally. 

Deafness  has  been  attributed  to  the  over-use  and  abuse  of  mer- 
cury, and  I  was  myself  once  under  the  impression  that  such 
might  happen,  from  having  seen  some  cases  of  almost  complete 
loss  of  hearing  in  persons  who,  it  was  stated,  had  taken  large  quan- 
tities of  mercury  for  a  long  time.  I  have  recently  made  particu* 
lar  inquiry  after  these  cases,  and  I  have  carefully  examined  the 
membrana  tympani  in  each,  and  in  every  case  I  found  it  thick* 
ened,  opaque,  and  manifesting  all  the  appearances  consequent 
upon  deposits  between  its  layers, — the  result,  no  doubt,  of  spe* 
cific  inflammation.  Each  of  these  cases  were  originally  syphilitic, 
and  exhibited  evident  traces  of  a  scrofulous  taint,  and  they  all 
acknowledged  that  they  had  taken  the  mercury  most  irregu- 
larly, and  had  been  for  years  affected  with  secondary  symptoms. 
I  think  it  yet  remains  to  be  proved  that  mercury  produces  inflam- 
mation of  either  the  eyes  or  ears.  Practitioners  of  the  present  day 
have  received,  as  by  a  sort  of  hereditary  tradition,  and  still  enter- 
tain the  idea  that  mercury  will  produce  iritis ;  and  the  homoeopaths 
flourish  the  assertion  whenever  and  wherever  an  opportunity 
offers,  as  a  proof  of  the  grand  principle  of  their  doctrine.  Is 
it  a  fact  that  mercury  taken  for  the  cure  of  other  diseases  than 
those  which  will  of  themselves  induce  inflammation  of  the  iris, 
the  sclerotic,  or  choroid, — such  as  syphilis,  rheumatism,  gout,  or 
scrofula, — has  ever  caused  the  train  of  symptoms  of  internal  in- 
flammation of  the  eye  generally  known  as  iritis? 

The  preparations  of  iodine  and  potassium  may  be  employed 
in  aural  affections,  and  will  be  found  efflcacious  just  as  they  act 
on  the  general  health  or  the  diseases  of  other  organs ;  so  likewise 
with  cod-liver  oil.  The  only  medicine  I  know  of  which  appears 
to  exercise  an  influence  upon  tinnitus  aurium  is  leopard's  bane, 
the  arnica  montana,  formerly  much  in  use  for  rheumatic  affec- 
tions, and  as  an  external  application  in  sprains  and  bruises.  The 
value  of  this  and  other  remedies  in  diseases  of  the  ear,  as  well  as 
their  mode  of  administration  or  application,  will  be  explained 
when  speaking  of  the  diseases  to  which  they  are  applicable. 




StatisUcs  of  St  Mark's  Hospital — Analogy  between  Diseases  of  the  Eye  and  Ear; 
Amanrosb  and  Nervous  Deafiiess. — The  Author's  Table  of  2385  Cases :  their  Dis- 
eases, Ages,  and  Sexes. — Kramer's  Statistics,  their  Value  and  Peculiarities. — ^Tscbar- 
ner's  Statistics. — ^Toynbee's  Pathological  InvestigatioDS. — The  Author's  Abstract  of 
200  Cases. — Proofe  of  Inflammatory  Action  in  Ear  Diseases. — ^Nosological  Arrange- 
ments of  Galen,  Buchanan,  Harvey,  Deleau,  Kramer,  Pilcher,  lincke,  &c.~The 
Anatomical  and  Pathological  Bases. — The  Author's  Clasdfication. 

THE  subject  of  vital  statistics  has  of  late  years  engaged  the  at* 
tention  of  the  scientific  world  more  than  at  any  former  pe- 
riod,  and  within  the  last  few  years  the  statistics  of  ear  diseases  have 
been  noticed  by  a  few  Continental  writers.  As,  however,  some 
time  must  elapse  before  an  exact  knowledge  of  aural  diseases  is 
arrived  at,  and  until  their  nomenclature  is  fixed,  such  variety 
must  exist  in  the  accounts  of  different  authors  as  to  lead  to  ap- 
parent discrepancy,  if  not  to  a  semblance  of  ignorance.  It  is 
not  as  in  general  medicine  or  surgery^  where  there  is  but  little 
danger  among  educated  practitioners  of  mistakes  in  registering 
cases  of  fever,  pneumonia,  peritonitis,  or  calculus  ; — in  diseases  of 
the  ear,  what  one  practitioner  would  call  nervous  deafness,  ano- 
ther might  believe  to  be  the  result  of  some  organic  lesion  conse- 
quent upon  inflammation,  &c. ;  and  so  the  proportion  which  the 
different  diseases  bear  to  one  another  or  the  whole  would  vary 
according  to  the  mode  of  registering,  and  the  amount  of  know- 
ledge and  peculiar  opinions  of  the  registrar.  As  therefore  statis- 
tics involve  nomenclature,  so  does  the  latter  subject  lead  us  to  the 
consideration  of  nosological  arrangement. 

The  earliest  and  most  complete  statistics  of  ear  diseases  pub- 
lished in  these  Kingdoms  were,  I  believe,  those  appended  to 
the  Report  of  St.  Mark's  Hospital  for  the  year  1844-45.  Since 
that  period  as  accurate  a  registry  has  been  kept  of  all  the 
cases  which  presented  as  the  means  and  appliances  at  any  public 



institution  can  afford,  and  the  results  thereof  have  appeared  from 
time  to  time  either  in  the  Annual  Reports  or  in  the  public  journals. 
I  do  not  think  it  possible  to  keep  a  sufficiently  accurate  account 
of  all  private  patients,  and  therefore  none  such  are  included  in 
these  returns.  From  the  1st  of  March,  1844,  to  the  Ist  October, 
1852,  as  shown  by  the  accompanying  Table  at  page  102,  the  num* 
ber  of  ear  patients  whose  diseases  were  registered  amounted  to 
2385 ; — besides  very  many  others  of  whose  disease  no  note  was 
taken  at  the  time. 

When  I  first  commenced  the  study  of  aural  diseases,  I  be- 
lieved that  in  most  cases  where  I  had  no  positive  evidence  of 
disease  in  the  meatus  or  membrana  tympani,  the  deafness  and 
tinnitus  were  caused  by  some  defect  in  the  nerve  of  hearing,  or 
what  is  termed  *'  nervous  deainess.**  As,  however,  my  field  of  ob- 
servation extended,  and  as  my  knowledge  of  the  healthy  and  mor- 
bid appearances  of  the  membrane  improved,  I  gradually  began  to 
find  that  the  instances  of  deafness  with  perfectly  healthy  Qrmpanal 
membranes  which  fell  under  my  observation  were  comparatively 
few :  while  I  daily  became  familiarized  with  a  variety  of  patholo- 
gical appearances  in  these  structures,  which  I  was  soon  convinced 
were  the  result  of  different  forms  of  inflammation  of  an  acute  or 
chronic  nature,  arising  from  some  idiopathic  or  specific  cause. 
These  appearances  naturally  led  me  to  pay  particular  attention  to 
those  diseases  in  their  early  stages, — the  only  period  at  which, 
in  most  of  them,  art  can  be  of  any  avail 

As  the  acquisition  of  knowledge  is  progressive,  so  my  means 
of  forming  an  accurate  diagnosis  improved  with  my  experience, 
and  therefore  the  value  to  be  sttached  to  the  early  years  included 
in  this  Table  is  not  so  great  as  that  for  a  later  period.  I  have  con- 
sequently divided  the  results  into  two  portions:  the  first  includ- 
ing three,  the  second  four  and  a  half,  years.  In  the  first  portion 
of  the  Table,  out  of  706  recorded  cases,  85  were  set  down  to 
^  nervous  deafness,**  which  I  am  inclined  to  think  was  an  exag- 
geration, as  by  a  more  carefully  conducted  examination,  and  with 
increased  experience,  I  found  but  18  cases  out  of  1679  in  the  second 
period ;  having  observed  since  the  former  period  that  many  of  the 
cases  attributed,  for  want  of  abetter  name,  to  "  nervous  deafness,** 


showed  such  manifest  appearances  of  diseased  action  in  the  mem- 
brana  tympani,  that  little  doubt  now  remains  upon  my  mind  that 
the  defect  of  hearing  was  to  be  attributed  not  to  paralysis  or  want 
of  power  in  the  auditory  nenres,  but  to  lesions  produced  by  in- 
flammation. Again,  in  the  first  period  there  is  no  entry  for 
thickening  and  opacity  of  the  membrana  tympani,  the  unmistake- 
able  result  of  inflammation,  but  as  many  as  219  in  the  second; 
and  under  the  head  of  inflammation  of  a  chronic  character,  we 
find  but  82  cases  noted  in  the  first,  and  314  in  the  second  period. 

Out  of  the  2385  cases  recorded  we  perceive  that  579  were 
simply  cases  of  impaired  hearing  produced  by  impaction  of  the 
external  auditory  passage  with  cerumen;  114  of  so-called  nervous 
deafness;  25  of  tinnitus  aurium,  unaccompanied  at  the  time  by 
deafness  or  any  apparent  disease ;  14  of  otalgia ;  7  of  deaf-dumb- 
ness, either  congenital  or  acquired ;  2  of  accidental  haemorrhage 
from  the  tympanal  cavity ;  7  of  congenital  malformation ;  20  of 
coUiqpsed  membrana  tympani ;  and  2  of  tumours  of  the  auricle: — 
making  in  all  but  770  diseases  of  the  ear  not  directly  traceable  to 
inflammation  or  its  effects. 

Let  us  reason  by  analogy  on  this  great  preponderance  of  in- 
flammatory affections  among  diseases  of  the  ear  from  what  may 
be  observed  of  the  organs  of  sight.  Out  of  11,233  eye  cases  regis- 
tered at'St.  Mark's  Hospital,  but  857  were  diseases  of  the  retina 
and  optic  nerve,  and  only  341  of  these  were  instances  of  un- 
complicated amaurosis,  or  about  1  in  every  33  of  the  entire.* 
Whereas  in  the  registry  of  ear  diseases  hereunto  appended,  the 
proporUon  of  nervous  deafness,  including  the  exaggerated  entry 
in  the  first  period  already  alluded  to,  is  about  1  in  21 ;  but  by  i^ 
more  accurate  registry  it  is  probable  that  it  would  bear  a  some- 
what less  proportion  to  the  whole  than  amaurosis  does  to  the  ge- 
neral mass  of  diseases  of  the  eye.  In  former  times  cases  of  loss  of 
vision  by  what  was  called  gutta  screna,  and  also  glaucoma,  were 
said  to  be  very  frequent.  Some  time  later,  owing  to  the  improved 
condition  of  ophthalmic  pathology  and  diagnosis,  observers  re- 
duced both  these  affections  to  a  smaller  compass  under  the  name 

*  See  Report  oa  the  Namber  and  Condition  of  the  Blind  ia  Ireland  in  Mufh,  1S51, 
in  the  Report  of  the  Ceneoi  Commiaaionen  for  that  period,  Pait  n.  page  45. 



of  amaurosis.  Still  more  recently,  and  as  practitioners  became 
better  acquainted  with  the  various  forms  of  congestion  and  other 
diseases  of  the  choroid,  and  the  different  silent  inflammations 
which  may  be  set  up  in  the  eye,  the  latter  disease  was  still  further 
reduced;  and  now  I  think  it  will  be  acknowledged  by  those  who 
have  enjoyed  extensive  opportunities  for  studying  ophthalmic 
affections,  that  ti'ue  uncomplicated  amaurosis,  not  resulting  from 
disease  of  the  brain  or  its  membranes,  or  tumours  within  the  cra- 
nium or  the  orbit,  but  proceeding  &om  simple  paralysis  of  the 
optic  nerve  or  retina,  are  comparatively  rare.  When  such  cases 
are  pronounced  incurable  at  a  public  institution  or  in  private 
practice,  and  are  either  told  so  honestly,  or  sent  to  the  country  to 
be  got  rid  of,  or  to  improve  their  health,  broken  down  by  disease 
or  treatment,  they  are  generally  lost  sight  of;  but  if  we  examine 
the  inmates  of  a  blind  asylum  we  are  at  once  struck  with  the  fact 
that  nine-tenths  of  the  cases  of  loss  of  vision  there  presented  are 
the  result  of  inflammatory  action  ;  the  cases  of  pure  unmixed 
amaurosis  are  comparatively  rare,  either  on  account  of  their  actual 
scarcity,  or  because  the  patients  so  affected  have  already  been 
carried  off  by  the  cerebral  disease,  which  was  the  original  cause 
of  their  blindness. 

From  an  analysis  of  the  following  Table  we  perceive  that  dis- 
eases of  the  auricle  and  external  meatus  amount  to  nearly  one- 
half  of  the  entire ;  affections  of  the  mcmbrana  tympani,  exclusive 
of  collapse,  number  819,  or  nearly  one-third  of  the  entire ;  and 
diseases  of  the  middle  ear  amount  to  101,  or  about  a  twenty-third 
of  the  whole.  The  term  otiUa  is  here  applied  solely  to  inflamma- 
tions of  the  cavity  of  the  tympanum ;  but  as  it  is  not  possible  to 
limit  inflammatory  action  to  the  peculiar  structure  in  which  it  is 
originally  set  up,  we  may  suppose  that  a  large  proportion  of  the 
diseases  registered  as  affections  of  the  external  drum-head  must 
have  extended  sooner  or  later  to  the  internal  surface  of  that  mem- 
brane, and  the  investitures  of  the  cavity  of  which  it  forms  the 
outer  boundary. 

The  subject  of  otorrhoea  is  difficult  to  manage,  either  in  a  sta- 
tistical or  a  nosological  point  of  view,  owing  to  the  variety  of 
causes  which  may  give  rise  to  that  affection,  the  different  portions 


of  the  ear  from  which  it  may  proceed,  its  various  complications, 
and  the  several  structures  which  may  be  originally  or  subse- 
quently engaged.  The  principal  division  made  of  that  disease 
in  the  Statistical  Table  is  into  external,  when  the  raembrana 
tympani  remains  intact:  and  internal,  from  the  circumstance  of 
its  perforation  or  total  destruction,  thereby  allowing  the  mucous 
membrane  of  the  middle  ear  to  be  exposed  to  the  action  of  the 
atmosphere.  The  eleven  cases  of  deaf-dumbness  must  not  be 
taken  as  indicative  of  the  real  proportion  which  that  affection 
bears  to  the  other  diseases  of  the  ear ;  in  this  country  the  number 
of  cases  of  congenital  deafness  applying  at  a  public  institution  are 
always  accidental.  The  statistics  of  that  class  are  set  forth  in 
Chapter  vii.  Of  the  entire  cases  recorded,  the  sexes  are  in  the 
proportion  of  100  males  to  79  females,  these  proportions,  however, 
vary  according  to  the  different  diseases :  thus  in  eczematous  and 
kindred  affections  of  the  auricle  and  meatus  the  females  predo- 
minated, whereas  among  the  cases  of  deafness  arising  from  col- 
lections of  cerumen,  the  male  sex  formed  the  majority.  In  cases 
attributed  to  nervous  deafness  the  females  predominated ;  whereas 
both  in  otorrhcea  and  all  tlie  inflammatory  affections,  the  sexes 
were  nearly  equal ;  but  cases  of  otorrhcea  attended  with  polypus 
were  much  more  frequent  in  the  male  than  in  the  female. 
With  respect  to  the  relative  frequency  of  aural  diseases  at  par- 
ticular periods  of  life,  the  following  Table  affords  accurate  infor- 
mation, as  the  ages  of  the  different  patients  were  carefully  regis* 
tered, — not  the  ages  at  which  the  disease  appeared,  but  that  at 
which  the  patients  applied  to  the  Institution.  This  Table,  it  must 
be  remembered,  does  not  include  all  the  diseases  enumerated  in 
the  Nosology,  or  specified  in  this  work,  as,  for  the  purposes  in- 
tended at  a  public  institution  too  minute  a  subdivision  would  be 
disadvantageous,  even  were  it  possible,  to  continue  it  for  a  num- 
ber of  years.  It  is  unnecessary  here  to  enter  further  into  its 
minutiae,  to  discuss  its  results,  or  enlarge  upon  the  deductions 
which  might  be  drawn  from  it;  like  all  such  Tables  it  must  be 
more  or  less  defective ;  but  so  long  as  statistical  calculations  are 
admitted  in  medicine,  it  is,  like  others  of  the  same  class,  entitled 
to  its  value. 

Tabu  jAomw^  Ot  difenmi  Dmam  cfOts  Ear,  rtffiMered  a 

Under  SJ  6  te  lit. 

CoogeoiUl  UaUbnaalioo  otExtenul  j 


AbnaiarMMildGUBd,  .  .  .  . 
DbMM  of  HHtoid  Pmctn,  .  .  .  . 
Ecuau  and  Herp™  "f  Auriek,  .  . 
Tnmoon  is  ditto, 

loinMtioD  ol  Exienal  llMttt^  . 
KUo,  with  AcoU  OtonlKB^     .   .   . 

Ditto,    „    Cbnnid     „ 

Otdfrhaa,  wUh  Polypoid  Gnwthi,  . 
AbK«M  In  EzWnua  Meatu*,  .  .  . 
CoDtnetioo  uul  UleeratioD  In  dilto,  . 
Vea^  Bodiet  in  ditto, 

imaicms  Colkctiolu  in  ditto,   .   . 

iiimwIlMi  cdCciabnuu  lympani, 

DHto,  SobMole  (StnuDooi),     .    .    , 

Ditto,  Sfphililic 

Ditto,  Ghnoie, 

Abcnu  in  Herobniui  TjfDpanl,   .   , 
Uicoration  and  Pcifontlon  of  lUUo, 

ThlckiniagtiHlOpkoityofMoiiibnui*  \ 
TfiapMi, I 

GruiiiUr  utd  TumUr  ditto,    .   .   . 

ColUpM  of  Mcmbrui*  Tympuii,  .    . 

iDflunimtion  oT  Carllu  l^iapml ', 
(OUlii), I 

Ditto,  with  Cwiei, 

Hamorrbag*  frciai  Tyinpuinm,     .    , 


Xertans  Dtafbou, 

PoK-Fcbrlle  Dofnew, 


DufDen  titm  Diieu*  of  Throai,  . 

SSSe      77     M    l«    118    148   U8 

SL  Mart't  Soapitid,/rom  Itt  MareJk,  1844.  to  Ut  October,  1853. 

8Ho40.[|*l  lo50.    Upwtni,. 

1811   1847 


AbKKu  ot  Maetoid  GUnd. 
Diwase  of  MoMoid  Proc«M. 
Ecuma  and  Herpes  oT  Auricle. 
TnmoDn!  in  ditto. 

Ditto,  with  AcQte  OtoirlKea. 
Ditks     „    Chroaio      „ 
OtOTTbow,  with  Pdiy^A  Orowthg, 
Abaceu  in  ExtDrnol  Meatus. 
ConlractioQ  and  Ulceratton  Id  ditto. 
VotAga  Bodies  in  ditto. 
CeramaiiODS  CoDectiotu  in  ditto. 

Ditto,  Subacute  (Slniroom). 
Ditto,  SiTiMlitic. 
ratto,  Chronic 

Abwoa  in  Hembnni  TjiapKi. 
:  Ulceration  and  Perfontioa  of  ditto, 
with  Otorrhea. 

J  Thickening  andOpadtj-orMembnuia 
Granalar  and  Taacnlai  ditto. 
CoUapH  of  Hembrana  Tympanl. 
Influnmation  of  Caritaa  Tapani 

Ditto,  Willi  Cariea. 
Hnmorrtiagg  from  Tympanom. 
T^nnilaa  Aorium. 

Ncrroui  Deafnesj. 
Post-Pebrilo  Deafneu. 
Deafhoa  from  Diiaan  of  Throat. 

104  ^*  '    KBAKBm's  STATISTICS. 

In  1845  Dr.  Kramer  published  his  BdtrSge  zur  Ohrenheilkundej 
in  which  he  has  given  an  extensive  statistical  chart  and  nineteen 
tables  connected  with  diseases  of  the  ear.     The  number  of  cases 
therein  recorded  amounted  to  2000,  of  which  but  5  were  diseases 
of  the  auricle,  and  281,  or  one-seventh,  of  the  whole,  were  dis- 
eases of  the  external  auditory  passage,  including  under  the  head 
of  inflammation  of  the  skin  213  cases  of  impactions  with  wax; 
a  position  which  yet  remains  to  be  proved.     He  includes  all  the 
diseases  of  the  tympanal  membrane  with  those  of  the  external  ear, 
whereas,  in  my  opinion,  they  belong  equally,  if  not  more  so,  to 
those  of  the  middle  ear :  indeed,  I  believe  that  the  chronic  as  well 
as  the  acute  inflammation  of  the  membrane  is  accompanied  by  dis- 
ease in  the  middle  ear  more  frequently  than  disease  in  the  audi- 
tory passage.  Of  the  2000  cases  observed,  the  inflammations  of  the 
tympanal  membrane  amounted  to  442,  or  something  less  than  one 
fourth  of  the  whole;  and  of  these  cases,  45  were  acute,  and  397 
chronic  inflammations.    164,  or  about  one-twelfth  of  the  whole, 
were  inflammations  of  the  middle  car,  but  which  he  does  not  tell 
us  were  originally  connected  with,  or  subsequently  produced 
changes  in,  the  mcmbrana  tympani.     If  in  these  164  cases  the 
inflammation  of  the  mucous  membrane  of  the  middle  ear  was  con- 
fined to  that  lining  the  bony  parietes  of  this  cavity, — not  extend- 
ing over  the  extensive  surface  stretched  upon  the  back  of  the 
membrana  tympani,  not  propagating  inflammatory  action  there, 
and  producing  the  effects  of  inflammation  upon  transparent  or  dia- 
phanous membranes, — as  we  sec  it  does  upon  the  aqueous  mem- 
brane lining  the  back  of  the  cornea, — then  have  we  no  analogy  for 
such  a  state  of  things  in  any  of  the  other  departments  of  patho- 
logy. To  these  164  cases  of  inflammation  of  the  lining  of  the  tym- 
panum, he  has  added  30  of  alterations  in  the  Eustachian  tube, — 28 
of  stricture,  and  2  of  occlusion,  —but  for  which  he  had  no  other 
warrant  than  that  he  was  unable  to  pass  air  or  solid  instruments 
through  the  tube.     There  were  4  cases  of  inflammation  of  the  pe- 
riosteum of  the  cavity — in  all,  198  diseases  of  the  middle  ear,  or 
one-tenth  of  the  whole.     Among  the  diseases  of  the  ear  he  has 
included  46  instances  of  deaf-dumbness.     With  most  of  these  sta- 
tistics we  find  no  fault;  and  to  the  various  tables  exhibiting  the 

kbambb's  statistics.  105 

causes,  ages,  sexes,  &c.,  we  must,  in  common  with  all  who  will 
examine  them,  award  to  the  zeal  and  industry  of  their  author  the 
amount  of  credit  which  they  deserve.  Some  of  these  tables  are, 
however,  more  curious  than  valuable ;  thus  No.  viii.  shows  the 
fatherland  or  country  of  his  different  patients  from  all  parts  of 
Europe  and  from  America  I 

When  we  come  to  examine  into  the  chief  cause  of  deafness 
enumerated  by  the  Berlin  aurist,  we  at  once  perceive  that  his  fa- 
vourite theory  of  "  nervous  deafness*'  has  been  pressed  into  the 
service,  and  this  item  made  to  exhibit  a  magnitude  which  we 
have  strong  hopes  of  seeing  Dr.  Kramer  himself  one  day  criticise 
with  more  severity  than  we  are  now  willing  to  do  for  him.  Of 
the  entire  number  of  cases  recorded,  1028,  or  somewhat  more 
than  one-half  of  the  whole,  are  set  down  as  ^^Nervose  Taubheii.'" 
The  most  that  can  be  said  of  these  1028  cases,  many  of  which 
may,  I  doubt  not,  have  been  caused  by  affections  of  the  auditory 
nerve,  is,  that  in  these,  the  parts  capable  of  inspection  exhibited 
to  his  eye  no  symptoms  of  disease.     In  which  case,  he  says,  **  the 
use  of  the  ear  catheter  is  the  only  means,  either  by  blowing  through 
it,  or  by  injecting  compressed  air  from  the  air-press,  or  by  the  in* 
troduction  of  a  catgut  string,  or  a  small  whalebone,  or  ivory  probe, 
to  learn  the  condition  of  the  Eustachian  tube  and  the  cavity  of 
the  tympanum,  and  thereby,  in  the  cases  in  question,  tojiidge  of 
the  condition  of  the  auditory  nerve^'!     But  even  this  hazardous 
mode  of  making  an  examination, — by  introducing  a  foreign  sub- 
stance into  the  cavity  of  the  tympanum ! — is  at  best  but  a  negative 
proof.     By  it  the  condition  of  the  ossicula,  the  membrane  of  the 
fenestra  rotunda,  the  fine  mucous  membrane,  with  its  nerves,  lin- 
ing the  tympanic  cavity,  the  state  of  the  labyrinth  and  the  inter- 
nal ear,  or  the  brain,  cannot  he  investigated*     Is  there  any  other 
organ  of  sense  in  which  the  affection  of  the  nerve  bears  the  same 
proportion  to  all  the  other  diseases  of  the  part  as  this?     Would 
any  table  of  the  affections  of  the  eye  be  acknowledged  as  authen- 
tic in  which  more  than  one-half  of  the  diseases  of  that  organ  were 
ascribed  to  amaurosis,  or  amaurosis  not  consequent  upon  some  in- 

*  A  very  admirable  analysis  of  Kramer's  Statistics  appeared  in  the  British  and  Fo- 
reign Msdieal  Benew  for  July,  1S47. 


flammatory  condition  ?  Let  us  ask  what  Dr.  Kramer  means  by 
nervous  deafness  ?  He  himself  answers,  in  the  first  edition  of  his 
JSrkenntniu  und  Heilung  der  OhrenkrankheUen,  that  such  cases  are 
those  in  which  **  we  find  the  hearing  altered  and  debilitated  with- 
out any  organic  abnormal  state  in  any  part  of  the  whole  organ  of 
hearing"  (see  Bennett's  translation,  page  255).  And  in  the  para* 
graph  following  he  adds,  with  great  justice,  ''This  nervous  deaf- 
ness has  hitherto  been  frequently  misused  as  a  cloak  for  ignorance 
and  want  of  skill  in  any  doubtful  or  obscure  disease  of  the  ear.** 
Now,  all  the  value  we  derive  from  the  foregoing  definition  is,  as 
already  stated,  that  the  examination  of  such  cases  afforded  nega> 
tive  evidence  as  to  the  existence  of  disease  at  the  moment  in  those 
parts  visible  to  the  eye,  or  the  condition  of  which  was  apprecia- 
able  by  the  ear  by  means  of  the  air-douche,  &c.  Sixteen  years 
ago  the  author  divided  this  nervous  deafness  into  that  attended 
with  tinnitus,  or  the  erethitic,  which  he  believed  to  be  amenable 
to  treatment,  and  the  torpid,  in  which  there  was  a  total  absence  of 
tinnitus  throughout  the  whole  course  of  the  disease.  Let  us  read 
from  Dr.  Bennett's  faithful  translation  of  the  work  just  alluded  to 
what  was  Dr.  Kramer's  exposition  of  the  physical  signs  of  nervous 
deafness  in  the  year  1836.  All  traces  of  cerumenous  secretion  va- 
nish by  degrees ;  the  Eustachian  tube,  as  also  the  middle  ear,  is  in 
general  firee  and  open,  and  a  stream  of  air  passes  readily  up  to  the 
tjrmpanal  membrane ;  and  then  he  says,  '*  In  both  forms  of  nervous 
deafness"  (i.e.  the  torpid  and  erethitic)  "I  have  almost  always/mmd 
the  membrana  tympani  white  like  paper ^  and  opaque ;  probably  in 
consequence  of  the  action  of  its  absorbent  vessels  having  been  im- 
paired.** Now,  had  Dr.  Kramer  been  conversant  with  the  normal, 
healthy  condition  of  the  membrana  tympani,  he  would  have  known 
that  it  was  shining,  diaphanous,  or  semi-transparent,  and  of  a  yel- 
low-grey tint  (except  toward  its  superior  attachment,  and  along  the 
line  of  insertion  of  the  handle  of  the  hammer  bone),  somewhat 
the  colour  of  gold-beater's  skin,  or,  what  bears  a  still  closer  simi- 
litude on  account  of  its  greater  thickness  and  fleshy  tint,  the  thin 
sheet  gutta  percha  which  has  been  lately  introduced  for  surgical 

To  state,  then,  that  a  texture,  the  normal  condition  of  which  is 


known  to  every  observer  of  it  in  the  living  healthy  state,*  to  be 
what  I  have  described,  is  '*  white  like  paper,  and  opaque,**  ex- 
hibits either  defective  powers  of  observation,  insufficient  means 
for  investigation,  or  a  want  of  knowledge  of  the  natural  condition 
of  the  parts.  What  would  be  thought  of  an  ophthalmic  surgeon 
who,  in  describing  a  case  of  amaurosis,  stated  that  all  the  structures 
were  normal,  but  that,  at  the  same  time,  the  cornea  was  opaque, 
or  even  cloudy  ?  Tes,  I  do  believe  that  in  the  cases  observed  by 
Kramer,  and  described  in  his  original  work,  the  membrana  tym* 
pani  was  opaque,  like  white  paper,  because  it  had  been  previously 
subjected  to  inflammatory  action,  and  the  opaque  deposit  was 
the  well-known  consequence  thereof  As  to  his  mode  of  account- 
ing for  the  opacity  by  a  want  of  action  in  the  absorbent  vessels, 
I  do  not  think  it  requires  refutation.  Some  of  the  worst  cases  of 
defective  hearing,  apparently  induced  by  paralysis  or  impaired 
function  of  the  auditory  nerves,  and  which  are  of  many  years' 
standing,  have  perfectly  normal  tympanal  membranes.  Further- 
more, if  those  cases  attributed  to  nervous  deafness  showed  such 
manifest  disease  in  the  external  membrane  of  the  tympanum, 
which  VH18  seen,  how  much  greater  may  not  have  been  the  morbid 
changes  in  the  parts  beyond  it,  both  in  the  middle  and  internal 
ear,  which  were  not  seen  ? 

In  the  Statistics  already  alluded  to.  Dr.  Kramer  modified  his 
former  views  as  regards  the  division  of  nervous  deafness,  and 
classified  both  under  the  general  head  of  diseases  of  the  inner  ear 
— as  nervdse  Taubheit.  Again,  in  1849,  in  the  second  edition  of 
his  principal  work  on  Diseases  of  the  Ear,  he  defines  the  affec- 
tions in  the  chapter  devoted  to  the  consideration  of  nervous  dis- 
eases of  the  inner  ear  as,  hard-hearingness,  and  deafness;  and 
without  any  preliminary  observations,  at  once  enters  into  the 
details  of  cases  and  observations  in  proof  of  the  so-called  nervous 

*  AnAtomists  seldom  see  the  membrana  tympani  except  in  the  dead  state,  when 
partial  decmnpoaition  has  set  in,  and  its  external  cnticalar  layer  has  become  thickened 
sod  opaque :  therefore  it  is  that  their  descriptions  of  this  stractore  are  not  as  accurate  as 
9i  other  parts  of  the  human  body.  Suppose  anatomists  were  to  describe  the  cornea  only 
from  the  condition  it  presents  in  subjects  five  or  six  days  dead,  how  little  would  have 
baen  writtea  about  the  polish,  traaq>arency,  and  curatnre  of  that  beautiful  stmctors! 


deafness.  And  in  almost  all  the  cases  recorded  in  that  section 
(p.  668,  from  No.  128  to  No.  165)  we  read  of  the  membrana  tym- 
pani  being  clear,  shining,  and  transparent,  thus  differing  from  his 
observations  made  in  1836,  when  the  same  structure  was  almost 
always  white  like  paper,  and  opaque. 

Mr.  Toynbee's  observations  and  dissections,  having  a  direct 
influence  on  the  statement  set  forth  in  these  statistics,  naturally 
attracted  much  attention,  and  would,  unless  disproved  by  counter 
facts,  be  a  "  heavy  blow  and  a  great  discouragement**  to  Dr. 
Kramer*8  views,  and,  consequently,  in  the  Medical  Times  and 
Gazette  (for  October  16th,  1852),  the  Prussian  surgeon  is  again 
in  print  on  the  subject, — fearful  that  his  English  professional 
brethren  should  not  fully  appreciate  the  results  of  his  "  exten- 
sive aural  practice  of  upwards  of  twenty-two  years.**  He  begs 
his  readers  to  be  satisfied  with  his  pathological  ( ?)  sketch  of  real, 
not  fancied  diseases,  in  contradistinction  to  the  researches  of  Mr. 
Toynbee.  Appended  to  that  paper  is  a  table,  republished  from 
page  113  of  his  OhrenheiUcundie  in  den  Jahren  1849  und  1850, 
giving  the  result  of  4000  cases, — 2000  additional  to  the  statistics 
published  in  1845, — ^and  there  again  nervous  diseases  of  the  ear 
are  made  to  exhibit  the  same  proportion  to  the  entire  which  they 
did  in  the  previous  calculations,  for  we  find  1875  cases  of  nervous 
deafness  out  of  the  additional  2000  set  down  under  the  respective 
heads  of  "  hardness  of  hearing,**  and  **  deafness.**  Time  and  pa- 
thological research  will  eventually  determine  the  matter  in  dis- 
pute, but  at  present  it  will  be  for  the  practical  surgeon  to  judge 
between  Mr.  Toynbee*s  dissections,  which  he  still  possesses,  and 
which  can  be  examined  by  any  person  who  pleases  to  wait  upon 
him,  — but  the  inferences  from  which  Kramer  says  "  are  of  a  purely 
theoretical  character,**  inducing  ''  false  consequences  and  conclu- 
sions,**— and  the  figures  given  as  the  result  of  the  latter  s  private 
practice,  and  set  forth  so  ostentatiously  in  his  various  publications. 

Let  the  profession  also  compare  the  result  of  the  observations 
and  brief  details  o(  facts  set  forth  in  the  tabulated  abstract  of  200 
cases  faithfully  taken  as  they  presented  at  a  public  hospital,  in  the 
presence  of,  and  equally  observed  by,  a  number  of  medical  men  and 
intelligent  students,  many  of  whom  will  no  doubt  recognise  these 


cases  when  they  read  them,  given  at  the  conclusion  of  this  chapter, 
with  the  figures  afforded  from  time  to  time  by  Dr.  Kramer. 
Far  be  it  from  me  to  deny  the  great  prevalence  of  what  is  termed 
nervous  deafness ;  in  the  foregoing  observations  I  merely  doubt 
the  proportion  which,  according  to  the  German  aurist's  belief, 
they  bear  to  the  entire  mass  of  diseases  of  the  organ  of  hearing. 
It  is  easy  to  give  names  to  diseases  and  to  attach  numbers  thereto, 
it  is  another  matter  faithfully  to  record  the  appearances  which 
each  case  presented  during  life  or  exhibited  after  death.  When 
Dr.  Kramer  has  demonstrated  to  a  public  class  of  students  and 
practitioners  capable  of  observing  for  themselves— the  only  true 
method  of  clinical  investigation — the  healthy  character  of  the 
membrana  tympani  in  one-half  of  the  next  2000  cases  which  he 
publishes,  I  think  his  figures  may,  but  not  until  then,  be  placed 
in  comparison  with  the  facts  described  by  British  observers.  Sta- 
tistical tables  and  calculations  are  really  valuable  only  when  we 
can  rely  upon  the  original  investigations  from  which  they  were 
deduced ;  if  the  materials  have  been  loosely  collected,  or  for  any 
special  purpose,  or  to  support  any  preconceived  theory,  such  cir* 
cumstances  naturally  influence  the  value  to  be  set  upon  all  sub- 
sequent arrangements,  no  matter  how  ingenious.  Statistical  cal- 
culations remind  one  of  the  kaleidoscope,  which,  when  turned  or 
shaken,  presents  new  and  beautiful  combinations  of  figure  and 
colour,  irrespective  of  the  objects  which  produced  such  being 
crooked  pins  and  glass  beads  or  spangles  and  diamonds. 

Dr.  Tschamer  of  Berne  published  in  1849  the  result  of  200 
cases  in  a  small  tract,  Beitrag  zur  StatiUik  der  Ohrenkrankheiten, 
the  sexes  being  in  the  proportion  of  115  men  to  85  women. 
Among  these,  both  ears  were  affected  in  158  cases ;  the  right  in 
22,  and  the  left  in  20.  The  diseases  recorded  affected  the  diffe- 
rent portions  of  the  organ  of  hearing  in  the  following  proportions: 
— The  auricle,  10;  external  meatus  and  auditory  canal,  163;  the 
membrana  tympani,  122 ;  the  cavitas  tjrmpani,  70 ;  the  Eusta- 
chian tube,  74;  and  the  labyrinth,  72:  but  the  diseases  affecting 
several  of  these  parts  co-existed.  The  proportion  of  diseases  of 
the  labyrinth  which  the  author  has  recorded,  and  which  we  are 
led  to  suppose  he  diagnosed,  would,  if  true,  be  curious.   It  is  un- 


neceaBary  to  follow  the  author  through  his  yarious  and  ingenious 
tables  further.  Mr.  Tearsley  and  Dr.  Schmalz  have  likewise 
written  upon,  and  published  tables  of  the  statistics  of^  ear  diseases. 

As  already  stated  at  page  37,  Mr.  Tojnbee  has  dissected  the 
ears  of  750  persons  furnished  to  him  from  different  sources ;  and  of 
these  he  has  published  the  result  of  the  examination  of  915  ears.* 
Of  these,  303  were  in  a  healthy  state ;  and  on  this  small  proportion 
of  only  one*third  found  in  a  normal  condition  the  author  remarks, 
"  To  those,  however,  who  have  given  the  subject  much  considera- 
tion, and  who  are  aware  of  the  wide-spread  prevalence  of  deafness 
in  its  varying  degrees  among  all  classes  of  society,  the  dissections 
will  not,  perhaps,  be  thought  to  exhibit  any  unusual  proportion 
of  diseased  to  healthy  specimens."*  Of  the  remaining  612  ears, 
184  had  belonged  to  persons  who  were  known  during  life  to  have 
been  deaf,  and  these  are  the  really  valuable  cases,  though  it  would 
have  much  increased  their  value  had  the  amount  of  deafness  and 
other  symptoms  during  life  been  recorded ;  70  showed  upon  dis- 
section such  manifest  traces  of  disease  as  left  little  doubt  that  the 
persons  must  have  had  in  life  defective  hearing ;  and  358  were 
believed  by  the  author  to  be  in  a  state  of  incipient  deafness.  The 
following  summary  gives  the  result  of  these  investigations ;  but 
so  many  ears  exhibited  morbid  appearances  in  different  parts,  that 
the  totals  of  the  different  sections  are  not  to  be  considered  as  mak- 
ing up  the  entire  612  ears. 

The  external  meatus  showed  disease  in  80  instances,  or  1  in 
10^:  consisting  of,— collections  of  cerumen  and  epithelium,  58; 
of  pus  and  epithelium,  13;  contraction  of  canal  with  alterations 
in  its  lining  membrane  and  osseous  parietes,  9. 

The  membrana  tympani  was  diseased  in  209  instances,  or 
nearly  1  in  every  3 ;  of  these  there  were,  with  the  membrane 
white,  thickened,  or  vascular,  52;  concave  externally  or  flat,  15; 
concave,  and  adhering  to  promontory,  21 ;  concave,  with  deposits 
of  calcareous  matter,  4;  perforated,  or  altogether  destroyed,  51 ; 
and  adherent  to,  or  connected  by  bands  with,  the  ossicula  or  pro- 
montory, 66. 

*  Sm  the  ICfldioo-Chirargical  TnnsactioiiA,  vols.  xxi?.  1S41,  zxtL  1848,  xxxiL 
1849,— this  Utt  containi  Ublet  for  the  entire. 

totnbbb'8  disssctioks.  Ill 

The  cavitas  tjmpani  presented  evidences  of  disease  in  the 
following  proportions :  it  contained  morbid  collections  in  107  ex- 
aminations, or  about  1  in  every  6,  to  speak  in  round  numbers; 
consisting  of, — collections  of  mucus,  with  the  lining  membrane 
healthy,  43;  and  with  the  membrane  thickened,  5;  filled  with 
portions  of  cerumen  and  epithelial  scales,  the  result  of  destruction 
or  perforation  of  the  membrana  tympani,  2 ;  containing  pus,  with 
the  membrane  thickened,  15 ;  filled  with  blood,  4;  with  serum  or 
lymph,  10;  scrofulous  matter,  20 ;  oily  matter,  1 ;  and  calcareous 
matter,  7. 

The  mucous  membrane  of  the  cavitas  tympani  was  diseased 
in  310  cases,  or  more  than  one-half  of  those  examined.  In  66  in- 
stances it  was  more  vascular  than  natural;  in  179  it  was  thick- 
ened; in  22  so  thick  as  to  bury  the  whole  of  the  stapes;  in  8  so 
thick  as  to  fill  the  tympanum ;  and  in  5  it  was  pulpy.  The  re- 
maining examinations  showed  the  membrane  ulcerated  and  thick, 
20;  with  black  pigment  secreted  beneath  it,  2 ;  with  blood  effused 
under  it,  8 ;  and  with  serum  in  the  same  position,  1.  It  is  pro- 
bable, however,  that  some  of  these  latter  appearances  may  have 
been  post-mortem  products,  and  that  many  of  the  characters  de« 
tailed  in  this  section  generally  may  have  resulted  from  the  dis- 
eases which  were  the  immediate  causes  of  death  in  the  patients, 
and  not  from  any  previous  affections  in  the  organs  of  hearing. 

Bands  of  adhesion  were  found  to  exist  in  the  cavity  of  the 
tympanum  in  179  cases,  or  1  in  3*42  of  the  whole.  These  bands 
passed  between  the  stapes  and  promontory  in  130  instances;  were 
connected  with  the  incus,  stapes,  and  promontory  in  8 ;  joined  the 
malleus  with  surrounding  parts  in  12 ;  connected  all  the  ossicles 
in  13;  the  ossicles  with  the  promontory  in  9 ;  the  tensor  tympani 
muscle  and  the  stapes  in  3 ;  and  the  chorda  tympani  nerve,  with 
the  adjacent  parts,  in  4. 

The  state  of  the  ossicula  is  thus  described:  the  malleus  adhe- 
rent to  the  promontory,  1 ;  removed  by  absorption,  ulceration,  or 
caries,  6 ;  and  found  with  incus  in  mastoid  cells,  1 ;  the  incus  was 
in  whole  or  in  part  removed  in  10  cases ;  disconnected  from  stapes 
and  malleus  in  3 ;  the  stapes  was  found  either  partially  or  com- 
pletely ancbylosed,  or  more  firmly  attached  than  natural  with  the 


fenestra  ovalis,  in  30  instances ;  disconnected  or  in  a  state  of  ab- 
sorption, 4 ;  and  projecting  into  vestibule,  1 ;  all  the  ossicles  were 
either  removed,  carious,  or  disconnected,  in  5  ears.  Thus  the 
number  of  cases  in  which  the  ossicles  were  diseased  or  displaced 
amounted  to  61,  or  one-tenth  of  the  whole,  a  proportion  which 
will  not  appear  exaggerated  to  persons  conversant  with  the  de- 
structive results  which  follow  otorrhoea  with  exposure  of  the 
tympanal  cavity. 

The  osseous  walls  of  the  tympanum  were :  thickened,  1 ;  car 
rious,  2 ;  partially  deficient  superiorly,  54 ;  and  inferiorly,  22. 
The  carotid  canal  was  contracted  3  tiroes,  making  in  all  82  cases 
of  disease  of  the  bony  parietes,  or  1  in  every  7-46. 

The  membrane  of  the  fenestra  rotunda  was  diseased  5  times ; 
the  tensor  tympani  muscle  atrophied,  7 ;  and  attached  to  stapes 

The  Eustachian  tube  showed  symptoms  of  disease  in  21  of  the 
examinations,  or  1  in  29 ;  contained  mucus,  10 ;  its  lining  mem- 
brane thickened,  vascular,  or  congested,  8 ;  and  with  bands  con- 
necting its  parietes,  3.  It  must,  however,  be  remarked  that  it 
was  only  the  upper  portion  of  the  tube  which  was  submitted  to 

The  internal  ear  exhibited  the  following  peculiarities :  the 
membranous  labyrinth  thickened,  4 ;  atrophied,  6 ;  the  labyrin- 
thine fluids  deficient,  8;  the  vestibule  and  cochlea  containing 
bloody  serum,  1 ;  pus,  1 ;  a  band  crossing  the  vestibule,  1. 

Considerable  difficulty  must  always  be  experienced  in  dis- 
^ctingf^or  in  discovering  pathological  changes  in  the  internal  ear, 
particularly  in  measuring  any  deficiency  of  its  natural  fluids.  We 
find  all  the  dissections  of  the  internal  ear  in  the  column  for  the 
184  persons  previously  known  to  be  deaf.  The  following  ob- 
servations upon  these  dissections  are  so  faithful,  and  so  much 
in  accordance  with  my  own  ideas  upon  the  subject,  that  I  in- 
sert them.  **  The'^fact  of  a  thickened  or  otherwise  deranged 
state  of  the  mucous  membrane  lining  the  tympanic  cavity  being 
one  of  the  most  common  pathological  conditions  of  the  organ  of 
hearing,  is  theH^roadest  general  result  of  the  dissections;  and  as 
cases  carefully  examined,  noted,  and  studied  as  they  have  arisen 


in  practice,  lead  to  the  same  conclusion,  I  have  little  hesitation 
in  stating  disease  of  that  membrane  to  be  the  most  usual  cause  of 
deafness.  What  are  the  history  and  symptoms  of  the  great  ma- 
jority of  cases  of  deafness  unattended  by  discharge?  Cold  has 
been  caught,  uneasiness  has  been  felt,  renewed  attacks  of  cold  have 
added  to  the  severity  of  the  symptoms ;  advice  is  at  length  sought, 
and  examination  shows  the  external  meatus  deprived  of  cerumeni 
and  frequently  deficient  in  natural  sensibility,  while,  towards  the 
membrana  tympani,  its  appearance  is  red  and  smooth ;  the  mem- 
brana  tympani  is  entire,  its  surface  shines,  but  it  is  hazy,  opaque, 
or  as  white  as  parchment,  and,  consequently,  the  handle  of  the 
malleus  may  be  discerned  with  varying  degrees  of  distinctness,  or 
cease  to  be  visible  at  all.  Upon  a  forcible  expiration  with  closed 
nostrils,  the  air,  by  means  of  the  otoscope,*  can  almost  always  be 
heard  to  enter  the  tympanum,  not  gradually,  however,  as  when 
the  organ  is  healthy,  but  with  a  puffing,  bubbling,  or  cracking 
sound,  as  though  impeded  in  its  progress.'* 

I  have  at  page  52  described  the  method  of  taking  cases  at  St 
Marks  Hospital.  The  history,  progress,  and  treatment  of  the 
first  twenty-four  cases  in  the  following  Registry  have  been  already 
detailed  at  length  in  the  Medical  Times  and  Gazette,  for  1851 
and  1852,  a  reference  to  which  will  show  the  manner  in  which  they 
were  reported ;  and  portions  of  them  are  inserted  in  the  body  of 
this  work.  The  remainder  are  susceptible  of  publication  like  the 
former,  did  space  permit.  From  the  voluminous  notes  of  these,  the 
following  abstract  of  200  instances  which  presented,  in  succes- 
sion, during  the  early  part  of  the  year  1850,  has  been  drawn  up. 
Many  other  cases  occurred  of  simple  impaction  of  the  external 
auditory  canal  with  cerumen,  which  have  not  been  included  in  the 
following  abstract,  except  where,  upon  the  removal  of  the  me- 
chanical impediment,  the  lining  of  the  canal,  or  the  external  sur- 
face of  the  membrana  tympani,  appeared  diseased  from  other 
causes,  or  in  consequence  of  the  long-continued  presence  of  the 
offending  body. 

^  Otoscope — an  eUstic  stethoacope,  eighteen  inches  long,  the  ends  tipped  with  ivory ; 
one  extremity  of  which  is  inserted  into  the  meatus  of  the  patient,  and  the  other  applied 
to  that  of  the  examiner. 











StMe  gf  Enmul  Mirtu  ud  CUal. 








Dry,   white,  and  poliihed  ;  l»d  ili»- 




chstK*  rormerlf . 


















Normal;     poat- 


■uralglind  in 

iBtUe  oTiup- 



1  moDth. 


Dry.  polished,  grey;  no  ceromeu.  .    . 









Pale  ;  more  polufaed  than  left.   .     .    . 






4  inches. 


niciii  on  it.  removal,  cuticle  thick- 











On  preuiire. 






through  which  a  reddixli  polypus  ap- 

peals, graving  frum  fuodua  of  canaL 





D«le.J  with  diachargci)  nicnibruii 




6  Inches. 


Filled    with    discharg.  ;     tnembnoe 



so  J 





On  pmssurt 


Dry  ind  scnly 






.■i  inche* 






2  mmlliiL 

1!  inch™. 



Dry  ;  no  cemmen 



3  inches. 


Filled  bv  an  abMeei  of  Intcgmneat.   . 






Itcmaykably  Mnall. 




3  inck«. 





16  J 







11  t 



B  inchai. 


Tilled  with  whilLh  diachargo.    .    .    . 






Filled  with  cerumen. 







Filled  with  hrown,  bard  cenuoen, 
thickened  and  detached. 





None  on  ei- 
ther udo. 


Stnall  dry,  pinkish  ;  no  cenimen. .    , 




U  d.j-,. 



di>.charge.    and    flake*   of  detached 

cuticle  I  men-brane  florid  red. 







Filled  with  muco-pamlent  ditcharge, 





3  month*. 


laioing  gUiry 


fluid  tn  belix. 



t  Mambrtna  Timpani. 

id  and  white ;  rough  and 

;  thickened ;  malleus  not 


led  than  on  right ;  a  crea- 

adty  occupies  lower  edge. 


hickened,  and  opaque. 

tl  pinkish  hue ;  crescentic 
aferiorly  ;  polished, 
collapsed ;  malleus  pro- 

with  red  patches.  .    .    . 

and  opaque ;  collapsed. . 

opaque,  and  reddish.  . 
ng  polypus,  membrana 
found  to  be  opaque  and 

Middle  Ear 
and  Eusta- 
chian Tube. 



;   opaque  ;  studded  with 
Ite  specks ;  collapsed. 
ired ;  thickened  by  inter- 
posit  ;  unpolished;  very 


ring  inferiorly ;    dense 
it  in  middle. 

spotted  by  grey  patches, 
white,  thicken^,  opaque; 
;e  vascular. 

rose-leaf  colour.  .  .  . 
f  layer  of  yellow  lymph. 



Membrane  ex- 
posed; deep- 
red,  smooth. 







ed,  red,  pulpy. 








Dull  throb-  . 
bing  in 





State  of 


Disease  attrl- 

Cold  and 

Severe,  lan- 
cinating ; 

None  at  pre 





Slight    and 


*  Siigiit.' 


Singing  and 






Falling  of 

Ix>ud  reports 



Tonsils  en- 


•       •       •       • 





red,  swollen. 


Uvula  elon- 

•       •       •       • 





Falling  into 
the  sea. 

Cold  and 




•       •       • 

whitish,  succulent,  and 

thickened, white;  slightly 
;  malleus  projecting. 
pots  of  yellow  lymph  ef- 

ill  aperture  in  upper  and 
part ;  air  passes  with 


Slightly  infla- 





Boiling  and 
loud  re- 

Loud  and  in 

Buzzing  and 


Auricle  hot, 
and  slightly 
painful.       I 















■Utt  or  KlWHl  MMBi  Md  CMd. 









ID    nnlK   of 
euh  lol». 


EliHimifd  «lit;  tdgti  nll^iwid:  oml 
while.  iluckuHd,  ui<l  rontaiits  auAj 

Ciuwd  bv  condylonula  Touml  mugia ; 
fetid  BUiioiu  discharge. 

D«n««l  one-third;  GUod  with  bnEOj 











p*n.  firn-red, 







oiu  nuJiiion. 
cnbrgrd,     ll. 
fiflHe  oblilcre- 
Ud;    ■  diuJty 

A  nsrroir  ■li^  filled  with  cnuU;  Uniw 







Filled  by  mtilberrr-lilte  tumoDT.  gnm- 
IcnJinE  into  ^""^ 












1  monlh, 

8  JMI*. 

1H  moothg. 



1  iucbo. 

8  India. 


4  ln>-hni. 

5  IncliH. 






Filled  with  cemmnL 

ConUini  thiclt  cueow  di>cturg«.  .   . 













3  wck.. 

fl  dB)». 

3  inch™. 



No  lobe. 

M.mbrw)e  tl.i<4a»d  and  polpr ,  ■ 






Dty  ind  conlnKted. 






4  Inchea. 







8  1ncb«>. 







14  run. 


0  inch«. 








lof  MHnbnxiA  T^mpftnL 

d  thickened. 


1  and  opaque. 

owing  to  thickening    of 
f  canaL 


ipaqne ;  like  parchment  . 
1,  opaqae,  and  collapsed.  . 
X  circumference ;  opaque  in 

)paque,  but  polished. 

Middle  Ear 
and  Eusta- 
chian Tube. 


ad  opaque, 
d  thickened. 

hickenedf  opaque ;  an  aper- 
e  of  pin*8  head  anteriorly, 
'  vibrating  bubble. 
1;  a  white  triangular  de- 
front  of  malleus. 
!,  opaque,  vascular.  .   .    . 

I  thickened. 

;  bk)od-red  superiorly.     . 

1  and  opaque,  showing  pre- 

I,  vascular ;  large  aperture 

,  dense,  white,  thickened ; 
re  of  vibrating  portion  a 
in,  depressed  spot,  with  ele- 
argin  from  previous  ulcer ; 
h  drde  inferiorly. 
ck,  opaque,  pearly,  dimmed. 
I  and  opaque. 







Originally  in 


for  earrings. 



Soreness  and 

On  pressure. 









Tumour  be- 
comes pain- 
ful     occa- 


Severe  pain 

at    night 


Came   on 

with  pain. 









•   .   •   . 


.    *    • 







.    *    .    • 


State  of 






Pain  on  ac- 
cession of 

Great,  like 
roaring  of 

In  head. 



Like  steam 
engine;  in- 
creased by 









Tonsils  en- 

Diaeaae  attri- 
buted to 




.   •   •   . 

of  head  and 


.   .   •   . 
Severe  cold 




A  blow  on 
the  ear. 


red  and 

Tonsils  en- 





Cold  and 
pain  in 
















a  jein. 



u.llv,  cutieuLu  on  exposed  ■uifuni 







4  iacbM.  on 



from  »ntetior  wall. 

Telluw  diicb^Ee  t  Urge  fUtitir  pofy- 











Eol.rg«l,  diy,  «.l3-,  t^nkiib  ;  paitl- 
lent  diKturgf^  with  ur  babbles. 










4  m'ouUu. 





Helis  (.l,lii»™l«l 

Filed  with  laseoM  depodt.    .... 


Killed  bv  inietl  polvpiu;  ditchain  . 
A  n,.re  .Ut,  d^-,  ,c*ly.  plugged  iri<k 

bani  Krumcn. 






14  d«y.. 
6  monlhi. 



cbarKB  b^n  three  dayB  ajtcr  pun, 
wbidh  then  ce»ed. 
DiminiKbfd.  loiv«, 
■Helling  mid  pain  in  nusloid  ivgkia 






15  )-™ni. 




Wall<  thickenrd,  opaqne ;  diichwn. 
Diy,  end  devoid  of  conunen       .    .   . 





3  monlba. 

t  foot. 


Filled  b7  dirk,  inlckr  cenuiuQ.     .   . 






11  ««ni. 
1  muuth. 

2  >ncb«. 


Dry,  devoid  or  cerunien 







e  incU«. 


Dry,  membrane  pinkish  io&iriotlr.     . 








6  J-™™. 



Lobe   nkcntcd 

(mm  diKlmrge. 


Thickened,   okented,  fllM  with  die- 

Devoid  rfcoramen 









Dry.  ecaly,  no  certmun  j  origioallr 

idiMhergF  of  bloody  fluid. 
Filled    by     condylomaU  i    Mid  dli- 

Dry,  dev(M  of  cerumen. 











1  of  Membrana  Timpani. 

and  Eusta- 
chian Tube. 



Bute  of 

Disease  attri- 

at  time  of  note,  owing  to 





x>lypii8  and  discharge. 

rtiaUy    visible  ;    whitUb, 

•       •       a       a 


'dear  and  perfect    .    .   . 


Like  bells. 

Glands  en- 
larged ;  the 
voice  very 


inferiorly ;  reddish  grana- 




.    •    .   . 

Bpfvwing  over  it. 

opaqae,  perforated.  .    .    . 

Inner  wall  of 
seen  through 





•       •       •       • 


•       •       •       • 



•   •   .   • 

unkisb,  perforated  in  centre. 

At  night 



•   •   *   . 
Sitting    at 

rhite,    mottled,    somewhat 



open  win- 

lacular,  perforated  inferiorly. 



Tinnitus  in 


Cold  and  ex- 


violent  at 

ear  and 


1     pinkish. 



ynn.  pinkish  tint   .... 


Severe,  with 

Frying  and 






1,  opaque,  has  lost  polish. 






que,  thickened  posteriorly, 


Much  at 

Beating  in 


Sleeping  in 

k  anteriorly. 


ear  and 

wet  clothes. 

;  a  dense  white  crescent 









Slight,   in- 



.   •   •   • 
Heats  and 

with  red  vessels;  malleus 

discernible;  its  site  marked 



paqae  line. 




Like  water- 

.   .    .    • 

.    .   •   • 

thickened,  irregularly  spot- 


colar  superiorly. 

tubes  free ;  air 
has  a  whist- 
ling sound. 



ok  over  outline  of  malleus. 






1,  vascular,    perforate    at 

Mucous  dis- 





charge  from. 

I   and    opaque,     vascular 

Only  occasion- 
ally pervious 
to  air. 


Buzzing  and 






Wet  and 

V             m 






;  defined,  crescentic  opacity 


jiink  colour. 

*       *       a        a 


a       a       *       a 


•      •      •       • 


•      •      •       • 



















F.  '25- 

Ear  !    Dnrmtion 

affec-'  of 

ted.  ,      Diaeue. 



^•'^^l     R. 
F.    50       R. 

H.   40 






M.   50 



25  < 


M.   40 


M.  !68 
F.  14 
F.    50 






F.   !60 








For  years. 

3  months. 

1  month. 

8  inches. 

5  inches. 
4  inches. 


5Iany  years. 

8  years. 


4  inches. 

2  inches. 

3  months.    Impaired  af- 
ter fits. 

State  of  Aariele. 


Hard,  elevated, 
sensitive  cica- 
trices on  helix. 



2  weeks. 

6  months. 

Xw  •      •      •      • 

2  we^s. 

2  years. 

10  years. 

L.   iMany  years. 

Ltm        \  .... 

L.      8  months. 



10  years. 

10  years. 
14  years. 

6  inches. 



3  inches. 








Helix  wanting. 
Flattened  by  long  j 
pressure   of  a 
hand  ;     helix 


State  of  Bxtoml  MeatBs  and  GanaL 

Dry,  no  oemmen.   •    • 

Dry  and  scaly.    .    .    . 


Filled  with  honey-like 
Mucous  secretioo,  «^*»>»«^«"mg  air  |^ 


Dnr  and  white. 


Contracted,  walla  thickened  ;  Bki 
with  crusts  of  insplasated  mQCOS; 
has  occasional  discharge. 

Membrane  thickened  and  pulpy ;  pio> 

fuse  discharge. 



Pinkish  at  lower  extremity.  .... 

Impacted  with  cerumen;  the  cntide 
of  canal  and  membrana  tympani  re- 
moved witli  it. 

Filled  with  hard  oenunen. 

Coated  with  discharge. 

Drv,  devoid  of  oemmen. 



Only  size  of  crow-qutU 

Walls,  touch  resembling  a  slit ;  lin- 
ing white,  thickened,  exuding  dis- 
charge ;  bottom  filled  with  hard 

Walls  white,  thickened ;  coated  with 

Filled  by  discharge ;  granular  po^jpoa. 

Dry,  devoid  of  i 



if  Membnna  TjmpanL 

Middle  Ear 
and  Eusta- 
chian Tube. 



State  of 

bated  to 

,   opaque  ;    atheromatoua 



like  car- 


•    .    •    * 

of  crescent  shape   poste- 


ottled  anteriorly ;  polished. 

and  opaque. 




.   .    •   . 


,  collapsed,  pinkbh.     .    . 





vascular ;  large  aperture 



•      •       •      • 


•      •      •      • 

iqoe,  dim ;   a  cicatrix  in 

Inflatable.     Occastooally 



Fall  on  back 

part  running  from  above 

like  steam- 

of  head. 

ds,  which  becomes  red  on 



;  bad  hsmorrhage  from 

street  rail- 



ollapsed;  centre  natural; 





lite  opacity^  with  deflned 


nd  inferior  circumference. 

•  left,  but  thin,  and  of  a 






k  colour. 

;  coe-half  destroyed  infe- 

Memb.    pulpy 
and  florid  red ; 
air  cannot  pass 
into     tympa- 
num ;   trying 
to  inflate  red- 
dens memb. 


Great  and 



inly  destroyed  ;  a  thick 




•       •      •       • 


itch  containing    malleus 

Ickened  on  both  sides.    . 


Fall  on  her 

rid  red,  granular.    .   .    . 




Cold  and 

rith  crescentic  opacity  at 

Inflatable;  in- 




•       •       •      • 

;e;  polished. 

creasing  co- 
lour in  H.  T. 

acnlar;  thickened,  opaque, 
skened;  pulpy  from  pres- 


•      •      •       • 





None  at  pre- 

.    .   «   . 


Scarhitina ; 

opaque;  white,  thick.    . 





opaque  ;  skim-milk  co- 



•       •       •       • 


and  opaque. 


ally  visible.     ... 





te,  mottled  with  pink. .    . 




A  cold 

skeoed,  white.     .... 


•      «      •      • 




liond,  tidaL 

'    NormaL 


|iaed,  thickened,  opaque. 


•      •      •      • 

BtGUTBT  or  BAB  ClSBft. 


SO  ;  H-  13 

87  ,   F. 


7.     8       I 

Imiwltd  with  d>rit  tat 

Xoraul-  Dnr,  uiJ  drtnd  ot « 

Nunoal.  Dry  and  lah ;  dp  ot 


Hisid   Tfd  ;    bony    protubnueB  K- 
Mchnl  >Dl«iarij  i    ' 

Long  utd  tortnuiu,  dcroid 

while      ■■       " 

1 1  Tran. 

NarmaL         '  Drr ;  lining 
IHlto.  I  Fillnl  wllb  > 

I  Diilo. 




to  of  Membnna  T^mpuil. 

and  Eusta- 
chian Tube. 



State  of 

Disease  attri- 
buted to 

1,  thickened,  pink;  small  slit 


Loud    and 


Sudden  cokL 

nfiy ;  air  whiatlea  through. 


llapsed;  dense  white;  trian- 




•    •   .    . 

.   .   •   • 

.pertare  anteriorly,  with  in- 

edges  ;   red  membrane  of 

ear  seen  through. 

>    layer    white,    thickened, 

Pains  in 

Severe;  ver- 


.   •   •   • 

adherent  to  cerumen. 



In  head. 

Blowing ; 



.   •   .   . 

1;  slightly  thickened ;  mot- 


ith  white   spots ;  vascular 



h  In  front  of  malleus.     .   . 





dtak  red ;  malleus  imper- 


In  suppuration 




•   •   •   . 

1,  thickened,  opaque ;  mal- 




.   .   •   • 

.    .   .   • 

ry  prominent 

with  whitish  exudation.     . 

•       •       •      • 

•    .    .    ■ 


•   .   •   • 

1,  thickened,  opaque;  slightly 

Inflatable ;  red- 

Pain   and 




;  dense  yellow  spot  l>efore 

ness  of  M.  T. 



increased ;  re- 
port on  inflat 







t  polished. 



A  grating. 



d,  opaque,  vascular  snpe- 




.   .   •   • 



Soreness  and 


«       •      • 











.   •   .   • 




.   •   ■   • 



.    •    .   • 

.   .   *    • 
Diving  in 


plainly  seen. 

the  sea. 

id,  opaque,  pinkish  crescent 






1y;  midleus  prominent. 

1,  unpolished,  white  above, 






am ;  malleus  prominent 

ipot  anteriorly,  thin,  trans- 

InflaUble;  in- 





projecting  like  elastic  mem- 

creases    pro- 

n ulcer  of  cornea. 


d,  vascular;  aperture  near 





.   •   .   • 

r  malleus. 

1,  red,  thickened 






id,  opaque ;  several  vascular 





Typhus  fe- 

ma; pink  crescent  inferiorly. 


1  thickened. 






id.  opaque,  pearl-coloured. 


.   .   •   • 



.   .    •   • 

1,  unpolished ;  malleus  pro- 






;  yellow,  atheromatous  de- 


1 ;  white  spot  in  centre. 




•   .   .   • 

.   .   •   ■ 

lertore  posteriorly.     .    .    . 

Mem.  villous. 



C.  tonsillitis. 


id  duIdv 




ID  dense  white 



•      •      tt      • 

e       e       a       tt 

like  skimmed  milk.      .    . 

•      •       •       • 





























Ear  I    Diintkm 
•ffec-.  of 

ted.  :     DiMtte. 

B.  ;  4  months. 
1  month. 











14  < 

80  < 












2  months. 
2  years. 

3  months. 

•    •    .    • 

8  vears. 



12  years. 

K.  j      Ditto. 

K.  I  Since  child- 
R.        4  years. 








9  years. 


6  months. 

•  •       •       • 

14  da  vs. 

6  years. 

•  •       •       • 

10  years. 

2  years. 
1  year. 

7  years. 

•       •       • 


4  years. 


1  inch. 


2  inchea. 

1  inch. 

4  inches. 




8  feet 


3  inches,  in- 
creased by 
1  inch. 



1  inch. 

2  inches. 

1  inch 


2  inches. 


6  inches. 

1  inch. 


1  inch. 

State  of  Awkle. 

















State  of] 

Dry  and  scaly.    . 
Pink,  moist,  some 


Filled  by  yellow,  bloody 

FiUed  by  insptasated  diaduuge.      .  . 



FiUed  by  caseona  matter, 

air  globules. 
Filled  by  thick  discharge. 

Enlarged,  dry,  pinkish ;  no  nmimi 

Dry,  scaly ;  normal  in  oolovr.  .   .  . 


Coated  with  discharge. 

Coated  with  fetid  discharge.  .... 

Normal •..    •.••• 


Filled  with  oermneo. 

Filled  with  oerumeo. , 


Dry ;  no  oemmen. 



Dry,  pinkish ;  no  cerumen.     .... 

Coated  with  discharge^  which  intannilii 

Filled  by  sanioos  diacluuge  - 
polypus  attached  poateriorly. 
No  cerumen.   •••...« 


White,  polished ;  no 
No  cerameo ;  pinkish. 



B  of  Manbniw  Tympani. 

Middle  Kar 
sad  £atta- 



State  of 

Disease  attri- 
buted to 

i ;  streaked  with  red.    .   . 






!ep  red  cresoent  inferiorly ; 

InflaUble;  in- 





scarlet  vessels  on  sorfaoe, 

creasing  red- 

ig from  point  of  malleus. 


n  light  pink. 





.                a        . 

ly  removed. 

White  bubble 

Great  origi- 

.      a       a       • 



in  Eustach. 


f^ial  pa- 



kened ;  red  and  yellow  spots. 


...       a 



pinkish  inferiorlj ;  bulged 






Is  in  pockets. 

d  and  white  throughout.    . 






d,  opaque ;  like  molfed  glass. 






d,  opaque  ;  small  aperture 






)  Eustachian  opening. 


Memb.   thick; 
exuding  blood. 






Slight  at 

Noise    in- 


Draught  of 

ots  ;    malleus    projecting, 



creased  by 

cold  air. 

bjr  white  line. 


aeotre ;  white  crescent  infe- 





.        a        .        . 

thickened,  and  granular.  . 


...       a 




thickened  posteriorly ;  vas- 






iteriorly,  with  small  valvu- 


Bd  colour. 





...       a 

J,  opaque,  dense  white.     . 


•      •      •      • 



Cold    after 

ickened ;  slightly  vascular, 
f  trotD  removing  cerumen. 

•       #       •       e 

•      •       •      • 

•       •      •      • 

*       •      •       • 

i,  opaque,  bluish  white.    . 







Loud  reports 



wrinkled  ;  a  uniform  pink 

Inflatable;  vas- 

Pain 'in- 

•     •      •      • 


Wet  feet 

cularity  of  M. 


T.  increased. 

at  night 

and,  deepening  in  centra; 










Paralysis  of 
fkce;  ptosis. 

^"•*  •«^^^^B  *i^*^^* 

pink  ;   aperture  in  centre, 

Mem.  deep  red; 





ite,  thickened  edge ;  malleus 

shadow  fh>m 

ipwards  and  backwards. 

edge  of  rent 

que,  with  red  spot  in  oen- 



•   .   .    . 


lUeos  not  discernible. 

Flowing  of 


...       a 

Head  shaved 

,  thickened ;  irregular  on 


In  ears  and 

i  yellow  inferiorly ;  whitish 



bDow,  irregular ;  dark  de- 

Inflatable ; 

Pain  origi- 




itericdy ;  white  streak  fklls 

M.  T.  projects 



in  pouches. 

ertore  anteriorly ;  its  edge 

Uninflatable ; 

•   •   •   • 




bickened,  inverted. 


1,  pink,  and  white.    .   .   .      SlighUy  infl. 










114'    F 


115  M. 

116  M. 

















-  -  - 

'  ~l 



{,  R.   I  1  year. 
:       I 

J-j»      I  •       •       •       • 

12       R.  6  months. 



















80  • 

R.      6  months. 
L.      18  months. 


R.   I  6  months. 

Ldt     •       •      •      •      . 












1  month. 
10  years. 

6  weeks. 

6  yean. 

8  years. 

6  years. 


State  orAwlele. 

2  inches.    iProtuberanoe  in 
front  of  tragus. 

2  inches. 



4  inches. 
2  inches. 

20  years. 
9  years. 

1  year. 
10  years. 

2  months. 


2  inches, 

2  inches. 
4  inches. 

I  inch. 

6  inches. 


4  inches. 

6  inches. 

None.      I 

14  inches. 

8  inches. 

















State  of 

Filled  with  mooo-paruloit  disduugeu 

Small  polypus  attached  anterioriy. 
Filled    by 

Hoist,  polished. 


Veiy  large ;  lining  xtormal,  bat  dry. 


Dry,  scaly,  containing  crusts  of  inspis- 
sated discharge,  which  ceased  klefy'. 

Coated  with  a  thin  discharge.    .   .  . 





Had  discharge  oo  three 

Ditta , 

Dry,  devoid  of  cerumen. 




Impacted  with  hard -...«„.    .   .   . 

Dry  and  scaly ;  had  diachai^ge  — »*fl 
two  years  aga 

Dry,  red ;  no  cemmeo.  ••..,, 
Dry  ;  membrane  pinkish. 


Dry  and  scaly. 








Hate  of 

nueh  thickoied  and  ool- 















Inf.,    H.  de<p 
biases   sqneel- 
ing  sound. 


Membrane  red 
pulpy  i  sha- 
dow thrown 
by  fragmen 

loos,  red. 





Inflatable;  can 
pre»  out  >pol 










Pain  origi- 

iterior  liair  deetroyed,  re- 

M  glau  :  zona  of  pinkiib 
ity  inferiutlr  ;  dense  white 
;wB«n  point  of  malleus  and 

right,  but  colUpsed,  want- 

erlorhalfdettmved:  mal- 
Ih  a  fragmenl  of  thickened 
oa,    drawn    upwirda    and 

own.  ;    «n.ll  opening 

fil«qoe.  mottled  with  pink, 
link,  deepening  interiorly  ; 

kim-milk  colour.  .... 
;  dense  1   red  veaseli  over 

,   <¥*q<K.    Uke   crumpled 

a«:ularily  at  inferior  edge, 
opaque,  dull ;  an  elevated 
in  tower  aoteriur  porUon. 

p.qoe,bntpoli.hrt.      .    . 
irregular    on   surface   by 
of  ooDcavities  and  con- 
it  in  centre-,  tta  edge  well 

,  opaqne,  like  old  pnrch- 
.  nd  etn.ak  ovsr  mallcua- 
,  imlisbed,  reflwlinB  liBlit 

■Llm-milk  colour     wbite 
lends  rrom  malleun. 
.,  moUled  with  white.  .   . 
lied  with  while  (  light  re- 

iKalar,  butpoUabed.    .   . 


Acute  origi- 

Mnch  (tor- 



On  find  ac 



Uke      run- 
ning w«er 




Boiling  wa- 
Beating  <^- 





Blow,  fol. 
towed  by 

from  R,  ear. 

A   severe 



BEQUTRT  OS  Elft  CA8S8. 


.    50  J 

.   30  j 

8  monllu. 
6  maath). 







FUttea«d   b/ 




Scily  ernption  «xl«dlD|K  into  nu 
tilled  by-  diadiu^  ;   mnrnll  polypoi 

from  upp«r  wall ;  luver  rtge  ulatH. 
t'uat«d  vilb  diw-htirge  and  cnuia, 

Dn-,  ililniDti,  vucuUl 

Enlarged  ;   filinl    with    khoroiu  M 

chat({«;  memti.  white  and  Uucfceaa 

Kll«d  with  oily  fluid 


A  Kale  of  dark  emunen  at  bouom. 
EDlargcd  ;   covered  with   dischaigt; 

polypua,  attached  aoterioiij. 
Drj  ;  bad  diachargn  fnjiooMfy. 


CoolracUd  ;  coated  with  dischAJgSi  . 
Thlekaned ;  lining  membrane  whitiik 


Normal.  .,,., 

Nurmal ;  very 


te  ;  nuall  ctiWnsia  rataiorij* 
'Tbickeoed  ;  bloody  diaduugv.  .   , 

LIniiiK  thickened  i  dry,  md.  . 
nUed  by  puruleol  ducharge. 

Lining  [unk  ;  poliabod.  . 

Long  and  toitaoog ;  dly. 
Nanvw  and  elliptical.     . 



9  of  If wihriiMi  Tywttftad. 

Middle  Ear 
and  Eusta- 



State  of 

bated  to 

khkkeiied ;  white,  bat  poUiihed 











with  scaly  inonutatioiL 

...       • 


I  uziiform  sheet  of  opsdty.  . 





arfonte ;  air  globule  reOects 

Inflat.  ;  water 





I  antero-inferior  portian. 

passes  throuf{h. 

id,  dense,  red 






pinkish,  vascular.  .... 






d  rsd  spots,  probably  nlcen. 






■               *va*#**B* 




•      •       •      • 


•       •       •       • 

iNnd  bj  white  band ;  a  de- 


spot  superiorly. 

ickened ;  a  large  aperture 





•      •      •      a 


presents  at 

d,  opaque,  rascular.  .    .    . 





•      •      •      • 

red ;  bulged  outwards.  .   . 

Gurgl  sound. 





red  :  malleus  unseen.     .   . 




Severe  sy- 


On  flrst  ac- 

*         %          9          # 



;  streaked  with  bright  red 





Facial  Paralysis. 


1;  traversed  by  pearUcoloured 





id  below;  bright  pink  above. 

Tymp.  cavity 

Most  severe. 




*,  like  conjunctiva  of  eyelid. 






bulged  into  meatus ;  dis- 




•      •       •      • 

•   .   .   • 


1,  opaque  above,  pink  below, 

Inflat.;  memb- 






made  vascular. 




•      •      •      • 




Uke  bells. 




9d  ;  red  over  malleus.     .    . 






Ch  vesicular  projections. 





.    .   •   . 

r,  like  ripe  raspberry.      .   . 





nt ;  white  ring  inferiorly.  . 





.   .    .   • 

irts  removed. 

M.  granular. 





id,  pearlaceous. 




•       •       •      • 


>Ctled  with  white 






as  in  aquo-capsnlitis.    .    . 





.    •    .   . 

'dsstroyed,  ossicles  and  rem- 





Small  Poz. 

Irawn  upwards  and  back- 


1  anteriorly;  malleus  unseen. 



•       •       •      • 

•              •              •             M 

1 ;  white ;  malleus  projecting. 






1,  white,  pulpy. 






vascular,  with  deep-red  spot 






re  of  anterior  part. 

lerture  inferiorly.    .... 

Memb.  villous. 




•       •       •       • 

E.  tube  closed. 





m  pink 

1,  Ugfaly  vaaeolar.     .  .  . 




•       •      •      • 



BBOnTBT  or  UB  CASB8. 

r  I 

.  38  J 


4  daj*.' 




Swall<Mi.  nd,  u 



1  Inch. 

Helix  wuiling; 


miulold  nfpBB 


ContncUd;  thickoMd ;  dlsdw 
nUcd  completely  with  Urgo  pd 
which  project*  eiwrcilly. 

Brown-Twi,  dry. , 

Dij,  sciij,  piok.    ...... 

Coatractcd ;  whitish  diachaiga, 
Monnsl ;  nevtr  had  discharge  . 




nilfld  with  poi  atid  Bir  bobblo 
Containa  thto  mnco-pnmlMtdki 
No  cgnuDBO ;  pinkiah.   .   .   . 


Teiy  red ;  bad  diaebarge  crigto 

Dry  and  poliahed. 

Swollen ;  coalAt  with  lymph  and 

purulent  discharge ;  Blled  by  ■ 

of  Indian  com. 
nr;  •.<»nmo. 

Oweotu  toCToacbmcot  pottniiwl 

charge  originally. 
Dry;  no  cemmon;  previooi  diM 

Filled  with  diacharge  umI  iIt  gli 

Dry,  waly. 

Filled  with  discharge.  .  ,  . 
Enlarged  ;  nneaml  with  diMlM 

Dry,  with  membraiM  tomgitol 

Filled  bj  NTeral  aoull  all  hi  aw 
Conlruted  ;  filled  irith  craMa  i 

nular  inn^orly ;  a  thin  acala  • 

Filled  by  discharge  and  air  glo) 
Filled  with  scales  and  cenm^ 
Filled  with  caaaea.  .... 


Saniooa  discharge  troni.  .  .  . 
FUbd  with  tcaUa  and  MrniMn. 



Middle  Ear 

of  Moabniw  T^peaL 

and  Eusta- 
chian Tube. 



State  of 

Diaesae  attri- 
buted to 







•       •       •       • 




1,  opaqoe,  poluhed.  .   .   . 


notUed,  poliahed.  .... 




•      •      •      • 

•      •       •       • 


Blowing  and 


•       •      •      • 

Scrofula  and 

Ite  ;  thickened ;  clear,  de- 

TnflaUble  in 

spoU  behind  malleiia,  and 



spine  dia- 

to  Boatachian  tube. 


inuned-milk  coloor,   with 





»      •      •      • 

mple  Interiorly. 

m  pink. 




^tlj  opalescent.    .... 




•       •      •      • 


a  palaating  rent  anteriorly. 






UaiMed,   opaque ;    malleus 





•  •       •       • 

•  •       •       • 

malleus  red. 

tch  anteriorly. 

;  white  below,  red  above. 





•       •       •       • 

i,  opaque,  like  old  parch- 





rascnlar  above. 

;  a  dense  purple  red,  but 


.   .   .   • 




;  malleus  prominent 

1;  small  aperture  inferiorly. 




•       •      •       • 






jrmpani  found  coated  with 


)  lymph. 

;  opaicity  inferiorly  ;  and 






In  concavity  posteriorly. 


,  opaque ;  irregular,  clear 





•   .   •   • 

m  posteriorly. 

,  thickened,  opaque ;  gra- 






;  perforate  opposite  Eusta- 


•      •      *      • 





ckened  ;  orange  red  infe- 





rossing  lower  part 

1,  opaque,  vascular.  .    .    . 


•      •      •      • 



nred,  rugged,  granular.     . 





.    •    .    . 

•milk  oobur ;  white  cres- 




.   .   •   . 



nred,  polished.  ..... 

at  night 

*       #      a       e 





•      •      •      • 


•      •       •       • 





Memb.  red. 

A  blow. 

»      •      •      • 

rhite ;  perforate  posteriorly. 

eorrugated,  with  clear  spots. 
•milk  colour  ;  spotted  with 

•      •      •      • 

Inflatable;  M. 

•       •       •       • 





red  over  malleus. 

T.  reddened. 

i   opacity    below  ;    white 





•       •       •      • 




•       •       •       • 



e        e        •       • 

■red  ;  mottled  with  white. 

•       •      •      • 

.   .   •    • 












1 88 






























SI  j 


10  1 




















MaM  or  EalMial  Ifaatna  a*l  » 






It. run. 


10  ynn. 




6  month*. 


1  ioch. 






1    IDCh. 

















1  root. 







Jformal;  auOoid 
gland  Bolaiged. 








HtUi  deficient. 

Mo  lobe. 


CoUapnd  to  m«r«  .Kt;  unm 

Piakub.  dry. 


Scaly;  coljcle  tfaickeoed.  .    . 

Fillod  bT  hard,  dark  ocman. 
HIW  by  thick,  yellow  di>dMi| 
WidHwd;  lUled  »hh  cmta.  . 



Enlarged ;  pink  :  iu  boUoa  SOi 
dlKhargo  and  lii  glolmkiL 


Red,  dry,  and  nlj.    .... 

5=-"':"^."— ' 

Dry,  Kah-;  Inlrodoetko  of , 
ind™  .pa«nodic  coughfa,. 

Wriokkd  ;  Kone  emoMa.      . 
HIM  by  diachargc  ,    nan  , 

rOM  with  oeranMi.  .... 


Exmriatod  with  diacfaun  ;  ■ 

b1«  and  polypnt            "^ 
Fillfd  with  roliddiadianeai^ 
Exroliated  and  filled  with  w 



Filled  with  oenmen  and  Ibi^ 



tto  of  Membnma  Tympani. 

r ;  an  ash-grey  ooloor.     .    . 

id,  thickened,  and  opaque.  . 
'  opaqoe ;  whitish  helow.  . 
below,  pink  above.  .  .  . 
ed;  malleos  unseen;  Facial 
lis  on  left  side, 
ext  layer  removed  with  wax. 
IT ;  perforate  inferiorly.  .  . 
led  i  pulsating  aperture  below. 


It  posteriorly. 

streaked  with  red.  .... 
sd,  thickened ;  malleus  red. 

and  thickened 

i  red  and  white  ;  small  aper- 
ypposite  Eustachian  opening, 
>  emits  a  whistling  sound. 

iy  normal 

ed,  like  crumpled  parchment 
ed ;  opaque  crescent  fnferiorly. 
irly  polished  ;  pink  zone  in- 

^  opaqae,  but  polished.  .  . 
ed ;  bright  pii^s  over  malleus. 

oUapsed ;  pink  above.  .  .  . 
led,  opaque,  vascular.  .  .  . 
t,  except  one  clear  spot  ante> 

led,  opaque,  like  parchment ; 

7  deejpena  at  inferior  edge, 

ver  malleus. 

ed,  thickened  ;  a  triangular, 

spot  below  malleus. 

ed,  thickened,  opaque.  .    .    . 

lent;  small  aperture  in  centre. 

ed,  polished  ;  malleus  promi- 

dear  in  middle  ;  crescent  of 

y  in  front. 

oly  thickened;  white  crescent 


Middle  Ear 
and  Eiuta- 
ohiaa  Tube. 


te  anteriorly. 

Md  and  much  collapsed.  .  . 
if  opacity,  with  clear  space  be- 
,  ndecting  light  over  large 
«,  but  decreased,  and  mem- 
bolged  ontwaid  on  inflation. 
led,  ooUapsedy  vaacnlar.  .   . 







Like  wind. 




Very  red. 

Memb.  white. 













Inflatable  ;mal- 
leus  becomes 






M.  hiflatable  in 

clear  spot 


Severe  at 








In  head. 


Pain  for  two 














like  wind. 

Like  milL 

















Tidal,  roar- 



State  of 



Memb.  red. 

•        •       a        • 



Tonsils  en- 


buted  to 



Cold  and 











«       •       •       • 



•  •       •       • 

•  •       •       • 



Wearing  1 
wet  cap. 

Fall  on  head. 




134  AV1LT8I8  OF  BB0I8TBT. 

Sess  and  Age. — From  an  examination  of  the  foregoing  R^stiy, 
we  learn  that  of  the  two  hundred  persons  affected,  101  were 
males,  and  99  females  ;  their  ages  being  in  the  following  propor- 
tions : — Under  five  years,  4  ;  from  five  to  ten  inclusive,  19 ;  from 
ten  to  twenty,  63;  twenty  to  forty,  82  ;  forty  to  sixty,  29  ;  and 
above  that  age,  3. 

Ear  affected, — In  27  instances  both  ears  were  similarly  and 
nearly  equally  affected,  in  which  case  a  single  entry  opponte  the 
letter  B  was  deemed  sufficient.  In  100  instances  both  ears  were 
diseased,  but  the  duration,  hearing  distance,  morbid  appearances, 
and,  in  some  cases,  the  cause,  varied  considerably  on  each  side. 
Generally  speaking,  the  ear  most  seriously  affected  is  that  first 
noted.  In  35,  the  right,  and  in  38,  the  left  ears  alone  were  af- 
fected. Where  the  record  of  but  one  ear  is  inserted,  the  other 
was  normal.  In  all  cases  the  entry  was  made  when  the  patient 
first  applied  at  the  Institution ;  the  progress  and  subsequent  ap- 
pearances,  increased  by  the  advances  of  disease,  or  modified  by 
treatment,  have  not  been  taken  into  account — the  object  being  to 
record  the  exact  state  in  which  each  case  of  a  given  number,  taken 
without  selection,  presented. 

It  must  be  remembered  that  all  these  cases  were  taken  down 
at  length  by  a  short-hand  writer,  and  that  the  condition  of  the 
meatus  and  the  state  of  the  membrana  tympani,  as  seen  through 
the  speculum,  were  the  two  principal  objects  attended  to.  In  cases 
of  manifest  disease  of  the  external  car,  or  upon  the  surface  of  the 
membrana  tympani, — sufficient  to  account  for  the  symptoms  pre- 
sented,— an  examination  of  the  state  of  the  tympanal  cavity  was 
seldom  made.  The  blanks  in  some  columns  show  that  the  symp- 
toms or  appearances  to  which  that  particular  space  is  devoted  were 
not,  in  those  instances,  present,  or  that  the  statement  of  the  patient 
on  that  point  was  unsatisfactory.  I  have  lately  had  a  form  of  regis- 
try  printed  for  the  Hospital,  containing,  in  addition  to  the  fore- 
going, columns  for  the  date,  definition  of  affection,  treatment,  and 
observations,  &c., — the  tabulated  results  of  which  will,  I  trust,  in 
time,  still  further  assist  the  examination  and  diagnosis  of  aural 

Dr.  Kramer,  in  his  review  of  my  writings  in  the  last  edition  of 
his  large  work  on  the  Ear,  says  that  I  have  been  illogical  in  my 


deductions ;  this  may,  possibly,  be  the  case,  but  I  beEere  it  will 
be  acknowledged  that,  in  medical  science,  one  well-established 
fact,  and  truthful  observation,  is  worth  a  hundred  syllogistically 
arranged  arguments. 

Duration  of  Disease, — The  duration  of  the  disease,  as  well  as 
the  hearing  distance,  is  difficult  to  tabulate,  owing  to  the  variation 
in  those  cases  where  both  ears  were  affected.  In  some  instances 
the  patients  gave  such  an  unsatisfactory  accoimt  of  their  disease^ 
that  the  most  which  could  be  gleaned  was,  that  they  had  been 
'^  deaf  for  years.**  As  a  general  result,  the  following  particulars 
flow  from  this  portion  of  the  examination : — In  27  persons,  the 
disease  was  within  one  month's  duration  ;  in  40,  from  one  to  six 
months;  in  17,  from  six  to  twelve;  45  persons  were  affected  from 
one  to  five  years  ;  29  from  five  to  ten  ;  and  34  over  that  period* 
In  the  analysis  of  this  column  the  duration  is  given  from  the  ear 
longest  affected. 

The  hearing  distance  observed  may  be  thus  classified  : — 70 
could  not  hear  the  watch  imder  any  circumstances ;  4  heard  on 
its  being  pressed  against  the  auricle;  61,  on  merely  touching  that 
part;  125,  within  six  inches;  22,  from  that  distance  to  three  feet 
and  upwards;  and  in  18  the  hearing  distance  was  either  normal 
or  unrecorded. 

The  auricle  was  healthy  in  264  instances  ;  presented  conge- 
nital peculiarities  in  10;  and  was  diseased  in  26. 

Ihe  state  of  the  meaJlus  and  external  andiiory  canal  may  be  thus 
defined : — Normal  in  68 ;  dry  and  devoid  of  cerumen,  with  the 
membrane  whiter  than  natural,  and  slightly  wrinkled,  or  pre- 
senting towards  its  outward  margin  a  few  dry  scales, — characte- 
ristics of  disease  in  the  neighbouring  structures  and  general  accom- 
paniments of  deafness, — 78.  It  was  coated  with  discharge,  the 
lining  thickened,  and  frequently  of  a  pink  colour  or  vascular,  or 
the  passage  filled  with  crusts  of  inspissated  mucus  from  previous 
discharge,  in  83  instances ;  and  of  these  cases,  18  had  polypi  grow- 
ing from  some  portion  of  the  canaL  In  25  cases  the  passage  was 
filled  with  cerumen  of  different  qualities  and  degrees  of  consis- 
tence; these,  however,  form  no  proportion  of  the  cases  of  deafness 
arising  fix>m  simple  impaction  with  cerumen  which  occurred  dur^ 

136  AVALT8I8  OF  BB0I8TBT. 

ing  the  period  when  the  foregoing  200  cases  were  recorded,  Imt 
are  inserted  in  the  Registry  on  account  of  other  abnormal  condi- 
tions which  presented,  both  as  regards  the  pathological  appear- 
ance of  the  membrana  tympani,  or  the  middle  ear,  on  the  remo- 
val of  the  offending  body.  In  26  cases  the  canal  was  inflamed; 
in  9  its  walls  were  so  much  thickened  or  approximated,  as  to 
give  the  external  auditory  aperture  the  appearance  of  a  mere 
slit ;  bony  growths  presented  in  4  instances ;  and  a  few  cases  oc- 
curred of  condylomata  and  other  protuberances  filling  up  the 
meatus ;  4  cases  of  congenital  peculiarities,  as  regards  the  length, 
width,  and  tortuosity  of  this  canal,  also  presented,  as  may  be 
learned  by  an  examination  of  the  cases  in  detail.  In  order  to 
economize  space,  much  contraction  was  obliged  to  be  used  in  the 
terms  employed  for  recording  the  state  both  of  the  external 
meatus  and  the  membrana  tympani. 

The  state  of  the  membrana  tympam  is  the  most  yaluable  result 
afforded  by  the  examination  of  these  cases.  In  10  instances  only 
was  it  found  natural,  so  that  such  may  fairly  be  stated  as  the  pro- 
portion of  cases  of  *' nervous  deafness."*  In  176  it  was  thickened 
and  opaque,  in  whole  or  in  part,  from  disease  of  its  external  layer, 
owing  to  inflammations  of  various  kinds — with  and  without  otor- 
rhoea,  pressure,  or  ulceration — from  deposits  of  lymph  between  its 
laminae,  or  from  thickening  or  vascularity  of  its  mucous  lining. 
These  opacities  varied  as  much  in  shade  as  the  same  forms  of 
disease  present  in  the  cornea — &om  a  slight  nebula  to  that  of  a 
dense  white  leucoma  ;  and  the  analogy  between  the  diseases  of 
these  two  structures,  the  cornea  and  membrana  tympani,  can  only 
be  appreciated  by  those  conversant  with  both.  Sometimes  it 
presented  a  slight  opalescence,  or  skimmed-milk  hue  ;  at  others, 
a  general  dense  opacity,  and  in  these  cases  the  membrane  was 
most  firequently  collapsed.  In  some  cases  the  opacity  presented 
a  mottled  appearance,  like  that  seen  on  the  back  of  the  cornea  in 
aquo-capsulitis ;  in  others  it  appeared  like  mother-of-pearl.  The 
most  frequent  site  of  isolated  dense  opacity  was  the  inferior  attach- 
ment of  the  membrane,  where  it  presented  a  crescentic  white 
band,  about  a  line  in  breadth,  and  somewhat  resembling  the  arcus 
senilis.    In  a  few  instances  a  dense  white  line  stretched  between 


the  extremity  of  the  malleus  and  some  point  of  the  circumference 
of  the  membrane.  Around  the  attachment  of  the  malleus  it  was 
frequently  thickened  and  opaque.  In  many  cases  there  was  a 
yellowish  tint  imparted  to  the  membrane,  which  gave  it  some- 
what the  appearance  of  old  or  crumpled  parchment. 

In  13  cases  there  were  connected  with  these  various  states  of 
opacity  thin  clear  spots  of  membrane,  about  the  size  of  mustard- 
seeds,  which,  when  air  was  pressed  into  the  cavity,  generally 
bulged  outwards  into  small  pouches  ;  and  this  phenomenon  oc- 
curred even  in  instances  in  which  the  membrane  as  a  whole  did 
not  appear  to  be  affected  by  the  volume  of  air.  It  is  not  impro- 
bable that  these  were  the  sites  of  ulcers  in  which  the  external 
layer,  or  the  internal  mucous  one,  had  been  removed,  and  the 
middle  fibrous  structure  remaining  unaffected  was  thus  pressed 
outwards  into  small  hemise.  Occasionally  the  whole  surface  of 
the  membrane  was  irregular. 

The  amount  of  polish  was  various :  in  many  cases  the  surface 
of  the  membrane  resembled  muffed  glass  ;  in  others,  although 
there  was  considerable  opacity,  the  normal  shining  character  was 
preserved,  and  light  reflected  in  the  usual  manner.  It  is  possible 
that  in  these  latter  cases  the  opacity  may  have  been  seated  in  the 
mucous  layer  lining  its  inner  surface. 

There  was  facial  paralysis  in  4  instances. 

In  4  cases  there  was  a  deposit  of  hard,  gritty  matter,  between 
the  laminae  of  the  membrane,  of  a  yellowish  colour,  with  a  sharp, 
defined  edge,  like  the  atheromatous  substance  formed  between 
the  coats  of  arteries. 

It  is  not,  in  the  present  condition  of  our  knowledge,  always 
possible  to  state  what  was  the  precise  form  of  inflammation  or 
other  disease  which  produced  the  effects  particularized  in  the 
foregoing  Registry,  which  merely  records  the  appearance  at  the 
moment,  and  the  pathological  results  of  previous  disease. 

In  121  cases  the  membrane  was  more  or  less  vascular;  some- 
times it  presented  a  uniform  pinkish  hue,  deepening  in  colour 
from  that  of  a  monthly  rose-leaf  to  that  of  a  bright  blood-red  or 
scarlet,  as  when  affected  with  recent  inflammation.  Occasionally 
the  redness  was  circumscribed,  presenting  a  zone  around  the  in- 

188  AVALTns  ov  Bionnnr. 

ferior  attachment  of  the  membrane,  not  unlike  that  aeen  in 
of  corneitis ;  in  others,  showing  Bereral  small  dots,  or  brighten- 
ing the  site  of  the  attachment  of  the  malleus.  In  noting  the  oasca, 
a  distinction  was  made  between  tints  of  colour  and  yascularilj; 
in  the  latter  the  red  vessels  were  distinct  and  plainlj  discemil^ 
Where  the  naturally-thickened  membrane  shelves  off  graduaUj 
into  the  roof  of  the  meatus  is  a  very  common  locality  for  redness 
and  vascularity,  even  in  otherwise  healthy  membranes.  Where 
distinct  vessels  could  be  traced,  they  were  generally  observable  in 
that  position,  or  coursing  from  above  downwards  along  the  manu* 
brium,  or  spreading  from  the  point  of  that  bone  to  the  posterior 
or  inferior  attachment  of  the  membrane.  In  some  instances  the 
whole  surface  was  not  only  of  a  deep  red,  but  also  granulart 
like  that  of  a  ripe  raspberry,  or  the  appearance  so  frequently 
presented  on  the  inside  of  the  upper  eyelid ; — such  were  cases  of 
long-continued  otorrhcaa.  Although  this  cameous  condition  was 
often  seen,  and  although  so  many  cases  of  otorrhcsa  and  polypus 
occurred,  I  have  never  observed  a  polypus  growing  from  the 
external  surface  of  the  membrana  tympani,  either  in  these  200 
cases,  or  in  the  many  hundred  ears  that  I  have  examined.  The 
general  red  colour,  as  well  as  the  distinct  vascularity,  was  always 
increased  by  any  attempt  made  by  the  patient,  whether  successful 
or  not,  to  force  air  into  the  tympanal  cavity.  That  blood  is  deci- 
dedly pressed  into  the  structures  of  the  ear  by  a  forced  expiration, 
or  inflation  after  the  manner  described  at  page  64  I  had  very 
recently  an  opportunity  of  determining.  I  removed  a  polypus  at* 
tached  by  a  fine  peduncle  to  the  anterior  wall  of  the  meatus,  near 
the  attachment  of  the  membrana  tympani ;  nothing  remained  of 
it  but  the  bright-red  spot  from  which  the  morbid  structure  grew. 
After  the  haemorrhage  ceased,  and  when  the  parts  were  brought 
into  the  field  of  the  speculum,  I  desired  the  patient  to  inflate 
the  drum,  when  I  remarked  that  each  time  he  did  so,  the  blood 
pumped  out  of  the  spot  from  which  the  polypus  had  been  cut. 

In  53  cases  the  membrana  tympani  was  more  or  less  collapsed, 
a  condition  already  referred  to  at  page  14,  and  the  cause  of  which 
would,  from  the  dissections  of  both  Mr.  Swan  and  Mr.  Toynbee, 
appear  to  be  adhesions  passing  through  the  cavitas  tympani, 


either  between  the  mucous  surface  of  the  membrane  itself,  or 
the  ossicula  connecting  it  with  the  inner  wall  of  that  cavity,  and 
thereby  limiting  their  and  its  motions.    In  the  majority  of  these 
instances,  neither  by  natural  nor  artificial  means  could  the  vibra- 
ting portion  of  the  membrane  be  pressed  outwards,  although  in 
some  of  these  cases  there  was  positive  proof,  by  catheterism  and 
the  air-pump,  that  the  Eustachian  tubes  were  free.    As  might 
naturally  be  expected  where  the  membrane  was  drawn  so  much 
inwards,  either  by  the  mechanical  causes  alluded  to,  or  from  pres* 
sure  of  the  external  atmosphere  where  the  Eustachian  tubes  were 
not  free,  the  malleus  projected  outwards,  considerably  beyond 
the  line  of  the  membrane,  which  dipped  from  it,  like  a  festoon, 
on  either  side.     The  great  bulk  of  these  cases  of  collapsed  mem« 
brane  also  showed  evidences  of  thickening  and  opacity.     The 
membrane  was  perforated  in  48  cases,  the  size  and  position  of  the 
aperture  presenting  great  variety.     In  most,  but  not  all  of  these^ 
the  air  passed  through  with  a  whistling,  squeeling,  bubbling,  or 
gurgling  sound, — each  peculiar  tone  being,  no  doubt,  produced 
by  the  size,  position,  and  valvular  character  of  the  aperture,  as 
well  as  the  fluids  through  which  the  stream  of  air  passed,  and 
possibly  also  by  the  condition  of  the  margin  of  the  hole,  which 
was  sometimes  thickened,  and  frequently  inverted.     In  25,  the 
perforation  existed  inferiorly  or  anteriorly,  opposite  the  opening 
of  the  Eustachian  tube  ;  in  10,  posteriorly  ;  and  in  13  the  great 
bulk  of  the  membrane  was  removed  ;  and  the  remnant,  with  the 
ossicles,  was  drawn  upwards  and  backwards,  while  the  cavity  of 
the  tympanum,  and  the  promontory  in  particular,  was  distinctly 
visible,  with  its  lining  membrane  red  and  villous.     In  22  instances 
the  membrana  tympani  was,  from  obstructions  in  the  canal,  unseen. 
The  state  of  the  middle  ear  and  Eustachian  tube  is  not  so  satis- 
factorily recorded  as  that  of  either  of  the  foregoing  subjects,  as  it 
is  not  possible  to  diagnose  with  accuracy  the  pathological  condi- 
tion of  this  unseen  cavity.    Where  manifest  disease  showed  in 
the  membrana  tympani,  or  where  that  structure  was  open — with 
muco-purulent  matter  pumping  through  it — it  may  be  fairly  sup- 
posed that  the  fine  mucous  lining  of  the  cavitas  tympani  could 
not  have  been  in  a  perfectly  healthy  condition.     Where  the  aper- 


ture  in  the  membrana  tympani  was  sufficiently  large  to  admit  of 
inspection  of  the  parts  beyond,  their  condition  is  generally  stated 
in  the  tenth  column  of  the  Registry.  The  cavity  was  exposed 
in  28  ears  ;  in  89  there  is  no  record  of  its  state ;  in  129  it  was 
inflatable,  and  in  73  uninflatable, — ^the  mode  of  examination 
being,  in  most  instances,  that  described  at  page  64.  In  many 
instances,  particularly  those  in  the  latter  portion  of  the  Registry, 
an  exploration  was  made  by  means  of  the  Eustachian  catheter  and 

Pain. — The  statement  given  on  this  point  must,  particularly 
in  cases  of  long  standing,  be  received  with  caution.  In  115  in- 
stances the  patients  had  experienced  pain,  either  in  one  or  both 
ears,  at  some  particular  period  of  the  disease.  In  124  cases 
they  stated  that  they  had  never  had  pain  ;  and  in  61,  the  notes 
from  which  this  Registry  has  been  compiled  make  no  statement 
upon  the  subject. 

Noise. — In  182  cases  there  was  tinnitus;  in  58,  none;  and  in 
60  there  is  no  record.  What  I  have  already  written  upon  the 
subject,  at  page  82,  may  serve  as  an  explanation  for  the  summary 
of  this  symptom. 

The  state  ofthroai  was  normal  in  181  cases  out  of  the  200,  a 
fact  which  goes  far  to  disprove  all  that  has  been  written  upon 
what  has  been  termed  **  throat  deafness ;'"  but  then  it  is  only  fair 
to  state,  that  enlarged  tonsils  are  rare  among  the  lower  orders. 

The  disease  teas  attributed  to  cold,  or  variations  of  temperature, 
by  sitting  opposite  a  broken  window,  or  being  exposed  to  a  draft 
of  air  in  a  railway-carriage,  &c.,  in  63  cases;  to  scarlatina,  in  14; 
fever,  8  ;  measles,  3 ;  influenza,  3 ;  scrofula,  4 ;  syphilis,  2 ;  and 
bathing  in  the  sea,  5 ;  injury  or  accident,  11 ;  occurred  after  partu- 
rition, 3 ;  followed  erysipelas,  2 ;  small-pox,  1 ;  intemperance,  1 ; 
and  in  the  remainder,  the  patients  were  unable  satisfactorily  to 
account  for  the  accession  of  disease.  It  must,  however,  be  borne 
in  mind  that  the  persons  from  whom  these  accounts  were  received 
belong  to  a  class  that  pay  but  little  attention  to  the  early  symp- 
toms of  deafness,  and  that  in  very  many  the  disease  approached 
gradually  and  without  warning.  In  children  and  young  persons 
the  flrst  symptoms  of  deafness  are,  unless  accompanied  by  pain  or 


discharge,  generally  unattended  to,  or  are  attributed  by  the  friends 
to  inattention  or  stupidity. 

From  the  records  of  the  foregoing  200  cases,  taken  indiscri- 
minately as  they  presented  at  a  public  institution,  as  well  as 
Mr.  Toynbee*8  dissections  already  detailed,  it  is  incontrovertibly 
manifest  that  inflammatory  affections  of  some  form  or  other  have 
been  the  chief  cause  of  aural  diseases.  This  conclusion  must,  I 
think,  be  conceded ;  and  it  is  of  vast  importance  that  the  Profes- 
sion should  be  convinced  on  that  point,  as,  on  the  one  hand,  it 
shows  not  only  the  inapplicability  of  the  various  nostrums  still  in 
use  for  '*  deafness,"  while,  on  the  other,  it  holds  out  a  fair  hope  of 
alleviating  diseases  of  the  ear,  if  taken  in  time,  by  the  ordinary 
means  in  use  for  arresting  inflammation  of  the  structures  engaged. 

That  a  large  proportion  of  diseases  of  the  ear  depend  upon 
constitutional  taint,  and  are  of  a  strumous  character,  is  well 
known  to  most  medical  practitioners.  In  some  of  Mr.  Toynbee's 
dissections  the  diseases  of  which  the  patients  died  have  been  re- 
corded. The  deaths  of  52  were  attributed  to  diseases  of  the  lungs, 
of  which  39  were  from  consumption.  Epidemic  diseases  carried 
off  24,  of  which  16  were  by  fever.  In  18  the  deaths  were  caused 
by  diseases  of  the  brain  or  nervous  system,  and  15  died  from  dis- 
eases of  the  digestive  organs. 

Those  only  who  have  been  engaged  in  accurately  recording 
cases,  and  compiling  statistics  therefrom,  can  well  understand  or 
appreciate  the  labour  necessary  to  effect  the  objects  intended. 
In  concluding  this  portion  of  my  work  I  would  earnestly  entreat 
those  gentlemen  connected  with  public  institutions  where  diseases 
of  the  ear  are  treated,  to  introduce  some  form  of  registry  by  which 
a  record  may  be  preserved  of  the  physical  signs  exhibited  in  cases 
of  deafness ;  and  occasionally  to  make  known  the  results. 

Having  now,  in  accordance  with  the  plan  laid  down  for  the 
arrangement  of  this  work,  given  some  account  of  the  principal 
writings  and  discoveries  connected  with  aural  surgery ;  having 
entered  fully  into  the  best  method  of  examination,  in  order  that 
an  accurate  diagnosis  might  be  formed;  and  having  also  dis- 
cussed the  subject  of  the  statistics  of  ear  diseases,  it  only  remains, 
before  I  enter  upon  their  description  and  treatment  in  detail. 


to  offer  some  Femarks  upon  the  best  nosological  airangement  of 
these  affections. 

To  the  difficulties  attending  all  synoptical  arrangements^  we 
have  here  to  encounter  additional  ones,  arising  from  the  obscurity 
of  the  parts  affected :  and,  whether  we  attempt  a  classification  ac- 
cording to  the  symptoms,  as  the  means  employed  by  CuUen  and 
Mason  6ood,^-or  base  it  upon  the  normal  or  morbid  anatomy  of 
the  tissues  affected,  as  by  our  modem  nosologists,  the  same  diffi- 
eulties  beset  us. 

The  earliest  chart  of  aural  diseases  worth  mentioning  is  that 
arranged  by  Cralen.  It  consists  of  five  affections,  viz. :  otalgia, 
baruckaia^  kophotis^  parakauds^  and  parakoutmata  ;  but  these,  it 
is  perfectly  evident,  were  but  symptoms,  not  diseases;  and  to 
these  he  added,  pain  in  the  ear  from  cold,  inflammation,  and 
*'  ex  flaJtaUnto  spiriiu  out  craitiB  H  vUoom  humaribus  eat  ex  eerom 
et  aanums  humoribuaJ^ 

The  first  attempt  at  an  arranged  nomenclature  of  aural  dis- 
eases in  Great  Britain  was  that  by  Buchanan  in  1825,  who,  in  his 
^  Illustrations  of  Acoustic  Surgery,^  endeavoured  to  classify  those 
affections  according  to  the  parts  engaged ;  but  his  diseases  are 
mere  symptoms.  It  contains  three  orders,  twelve  genera,  and 
thirty-three  varieties  ;  that,  however,  his  division  is  most  imper- 
feet,  nay,  in  some  respects,  absurd,  may  be  learned  by  an  exami- 
tion  of  his  fourth  genus  alone,  styled,  '*  Impedimeniwn  Externum^ 
or  obstruction  of  the  external  meatus,  under  which  he  enume- 
rates four  species,  each  resulting  from  causes  totally  different,  and 
quite  unconnected  with  one  another,  viz. :  "  Impedimentum  Ex' 
traneum^  from  extraneous  substances ;  Impedimentum  Induraiun^ 
from  indurated  wax ;  Impedimentum  Polt/posum^  from  polypi ; 
and  Impedimentum  Excrescens,  from  excrescences** !  I 

At  page  35  I  alluded  to  Mr.  Uarvey*s  '*  Synopsis  of  the  Dis- 
eases of  the  Human  Ear,**  published  some  years  ago,  and  offered 
an  opinion  as  to  its  value  and  peculiarities.  As  a  further  ex- 
ample, we  find  in  Class  II.  (qucere  III.)»  Order  i.  Laburinthos— « 
variety  of  diseases : — Inflammations,  ulcerations,  perforations,  ex- 
crescences, concretions,  hydatids,  effusions  of  blood,  formations  of 
pus,  &c.,  &c.  affecting  the  labyrinth,  and  also  the  fluid  of  that 


cayity,  but  expressed  in  high-sounding,  Chreek-derived  tenns,  for 
which,  as  special  diseases,  there  is  no  warrant  that  I  am  aware  of. 
It  is  high  time  to  get  rid  of  such  attempts,  which  merely  mystify 
the  student,  and  serve  to  frighten  the  patient.  If  we  want  com- 
plexity of  nomenclature  in  diseases  of  the  ear  we  had  better  apply 
to  the  Chinese  or  the  Hindus.* 

The  anatomical  division  into  the  external,  middle,  and  inter- 
nal ear,  presents  a  natural  basis  for  classification,  and  such  was  the 
method  adopted  by  Du  Vemey.  Deleau's  Table  is  perhaps  the 
most  artificial,  and  at  the  same  time  incomplete ;  he  gives  five 
classes,  two  of  which  are  devoted  to  affections  of  the  Eustachian 
tube :  the  first  is  divided  into  two  orders,  for  the  alterations  pro- 
duced in  its  naso-guttural  orifice  by  pharyngeal  disease,  one  by 
chronic  inflammation,  the  other  firom  enlarged  tonsils, — an  idea 
that  has  been  much  enlarged  and  improved  upon  in  England, 
although  I  have  not  yet  heard  of  a  single  dissection  showing  that 
an  indurated  tonsil  in  any  way  pressed  upon  or  produced  an  alte- 
ration in  the  trumpet-mouth  of  that  canal.  The  second  class  con- 
tains three  orders,  consisting  of  simple  obstruction,  chronic  inflam- 
mation, and  stricture  of  the  upper  portion  of  the  tube,  not  pro- 
duced by  disease  in  the  pharynx,  but  all  arranged  to  meet  the 
author's  peculiar  views  with  respect  to  Eustachian  catheterism 
and  aural  auscultation.  His  third  class  consists  of  inflammation 
without  secretion,  and  muculent  accumulation  in  the  cavity  of  the 
tympanum ;  the  fourth  includes  inflammation  and  perforation  of 
the  membrana  tympani ;  and  the  fifth  is  devoted  to  complications 
attending  diseases  of  the  middle  ear,  the  first  and  second  orders  of 
which  are  simply  combinations  of  the  foregoing ;  and  the  third 
order  includes  diseases  of  the  middle  ear  and  labyrinth. 

In  the  two  first  editions  of  his  work  on  Diseases  of  the  Ear, 
Ejramer  adopted  the  original  division  of  Du  Vemey,  but  mingled 
the  anatomical  and  pathological  basis  in  the  subdivision  of  the 
diseases  of  these  parts ;  as  for  instance,  erysipelatous  and  phleg- 
monous inflammations,  and  also  inflammations  of  the  glandular, 

*  See  Commentary  on  the  Hindu  System  of  Medicine,  by  T.  A.  Wise,  M.  D.,  Calcntta, 
1S45,  pi«e  2S7. 


cellular,  and  periosteal  structures.  In  the  last  edition  of  his  work 
he  adheres  throughout  to  the  anatomical  basis,  as,  for  instance,  in- 
flammation of  the  cuticle,  the  cutis,  the  cellular  membrane,  ma- 
cous  tissue,  and  periosteum,  &c. 

Mr.  Wharton  Jones's  arrangement  is  entirely  an  anatomical 
one,  consisting  of  two  parts,  viz.:  the  diseases  of  the  acceasoij 
organs  of  the  apparatus  of  hearing, — and  the  diseases  of  the  fun- 
damental organ  of  hearing, — the  ear-bulb,  or  labyrinth, — with  the 
minute  subdivisions  of  both  these  portions. 

Mr.  Williams  does  not  attempt  any  classification  whatever; 
and  Mr.  Pilcher*s  work  is  likewise  defective  in  this  respect,  hb 
arrangement  being  a  simple  enumeration  of  aural  affections,  di- 
vided into— the  abnormal  conditions  or  malformaUons ;  otitis,  or 
acute  inflammation ;  chronic  diseases  of  the  ear;  and  nervous  dis- 
eases of  the  ear. 

Lincke  is  by  far  the  best  modem  classifier:  he  makes  three 
divisions ;  but  he  does  not  classify  the  diseases  of  the  sentient 
portion  of  the  auditory  apparatus,  or  those  producing  nervous 
deafness.  We  hope  to  see  a  third  volume  from  this  author  on  these 
obscure  forms  of  disease.     In  the  first  division  we  find — 


Sec  I. — Simple.  Seg.II. — Complicated  and  Specific 

Outer  Ear. — Attritus   Auricu-  Otitis,  Erysipelatosa. 

lae.  „  Catarrhalis. 

Erythema  Auriculae.  „  Gonorrhoica. 

Inflamraatio  Auriculae  Phleg-  „  Rheumatica. 

monosa.  „  Arthritica,  s.  Otagra. 

Pernio  Auriculae,  a  frigore.  „  Scrophulosa. 

Infiammatio    Meatus   Audi-  „  Syphilitica. 

torii.  „  Morbillosa. 

InflammatioMembranaTym-  „  Scarlatinosa. 

pani  (Myringitis).  „  Variolosa. 

JdiddleEar. — Otitis  Universalis  „  Eczematica  s.CrustaLac- 

8.  totalis  interna.  tea. 

Infiammatio  Tubae  Eustachi-  „  Herpetica. 

anae  (Syringitis). 


His  second  division  includes — 


Contusio  Auriculae.  Vulnera  Totalis  Auris. 

Vulnera  Auriculae.  Coloboma  Auriculae. 

Fractura  Auriculae.  Foramina  Membranae  Tympani. 
Vulnera  Membrana  Tympani. 

The  third  division  consists  of — 


Dilatatio  Meatus  Auditorii.  Strictura  tubae  Eustachii. 

Strictura  Meatus  Auditorii.  Obturatio  tubae  Eustachii. 

Compressio  s.  Thlipsis  Meatus  CoUapsus  tubae  Eustachii. 

Auditorii.  Obliteratio  tubae  Eustachii. 

CoUapsus  Meatus  Auditorii.  Imperforatio  tubae  Eustachii. 

Atresia  s.  Obliteratio  Meatus  Aneurisma  et  Varix  Auriculae. 

Auditorii.  Cirsomyringa.* 
Dilatatio  tubae  Eustachii. 

I  was  indebted  to  this  enumeration  of  Lincke's  for  the  first  ac- 
count of  some  of  the  diseases  I  introduced  into  the  original  edition 
of  the  accompanying  Nosological  Table. 

In  Part  II.  of  my  Contributions  to  Aural  Surgery,  published  in 
1844, 1  gave  a  Nosological  Chart  of  Diseases  of  the  Ear,  "  more  for 
the  purpose  of  eliciting  inquiry,  and  as  a  basis  for  future  investi- 
gations, than  as  possessing  any  great  merit  of  its  own."  The  ge- 
neral principles  upon  which  that  arrangement  was  based  I  still 
adhere  to,  viz. — the  primary  divisions  into  the  diseases  of  the 
auricle  and  external  ear,  with  the  mastoid  and  pre-auricular  re- 
gions— in  fact,  all  the  parts  visible  to  the  unassisted  eye,  or 
which  can  be  appreciated  by  the  touch ; — those  of  the  external 
meatus  and  auditory  canal ;  the  affections  of  the  membrana  tym- 
pani ;  those  of  the  middle  ear,  or  cavity  of  the  tympanum ;  the 
morbid  conditions  of  the  Eustachian  tube;  and  lastly,  the  dis- 
eases of  the  internal  ear,  so  far  as  they  have  been  recorded  by 

*  Handbnch  der  theoretischen  and  practischen  Ohrenheilkunde, — von  Dr.  Carl  Gnstav 
Lincke.  Zweiter  Band.  Die  Noflologte  and  Therapie  der  Ohrenkrankheiten.  Leipzig, 
1840.     Referred  to  at  page  30. 



authors  or  have  passed  under  my  own  observations.  While, 
liowever,  this  anatomical  division  serves  as  a  basis  for  the  orders, 
and,  to  a  certain  degree,  influences  the  division  into  genera,  in 
accordance  with  the  structure  affected,  it  is  not  possible,  consis- 
tently with  the  phenomena  of  disease,  to  carry  it  beyond  that 
point,  and  therefore  the  species  and  varieties  of  diseases  and  acci- 
dents arc  not  confined  to  particular  structures,  but  arc  classified 
according  to  their  symptoms  and  the  other  peculiarities  of  the 
affections  themselves.  As  it  is  not  possible  to  limit  disease,  espe- 
cially of  an  inflammatory  character,  to  any  particular  structure, 
so  is  it  impossible  to  carry  the  anatomical  division  beyond  a  cer- 
tjiin  extent. 

In  this  classification  I  have  inserted  most  of  the  congenital  mal- 
formations and  a  few  rare  diseases,  upon  the  authority  of  credible 
authors,  but  with  these  exceptions  the  rest  have  passed  under  my 
own  observation.  I  have  also  reduced  the  nomenclature  as  far  as 
possible  to  English.  The  chief  alteration  in  the  present  arrange- 
ment consists  ol  the  position  given  to  the  various  a&ections  produc- 
ing discharge  from  the  meatus,  and  known  under  the  terra  Otor- 
rhasa,  which  I  have  distributed  according  to  the  original  locality 
or  structure  affected;  but  owing  to  the  great  importance  of  this 
symptom,  its  frequency  in  these  countries,  the  variety  of  morbid 
products,  even  in  remote  structures,  which  it  may  produce,  and 
the  fatal  results  which  sometimes  attend  it,  I  have  devoted  a  sepa- 
rate chapter  to  its  consideration.  The  number  of  inflammations 
which  may  give  rise  to,  and  the  variety  of  structures  from  which, 
discharges  from  the  ear  may  proceed,  either  originally  or  by  sub- 
sequent extension,  prove  the  impossibility  of  retaining  the  anato- 
mical division  beyond  a  certain  point.  There  are  some  diseases 
in  the  accompanying  table  which  belong  as  much  to  one  division 
as  another,  for  instance,  those  of  the  membrana  tympani ;  and 
again,  there  are  others, — at  least  such  well-marked  symptoms  as 
to  have  acquired  the  names,  if  not  the  importance,  of  disease, — 
which  it  is  diflicult  to  place,  from  our  not  perfectly  understanding 
where  they  have  their  seat,  as  otalgia  and  tinnitus  aurium ;  but 
these  are  objections  to  which  every  synoptical  arrangement  must 
be  liable. 



'  Impeifacl  or  IrnsgnUr  developmeiil. 

Incised  nounila. 

Arwuffnotn  or  thk  Suh. 

Aywtanotii  of  the  Maktoi 

Contused  lio. 

Fracture  uF  curtiliige. 
(  Fluttening  uid  obliteration  uf  h>' 
(  Slougbing  and  gangrene. 

Keloid  and  fibrous, 
liyiwrtropliy  snd  fatty  depoiit. 
PhlaginDncu.i— JilTu^eO  am!  clrcumMribiil. 
TnKi{H'hiioii«_ai;utc  and  chronic. 

Q  uf  maaloid  pcrioalenm. 

of  mastoid  gland. 
'nn  on  mastoid  process. 


r  Meatus  wanting  in  bone  and  curtiUgs. 


DiMAMB  or  CBnuiuaous  GuAims. 


i  contracted  or  Coitnooa. 

I  closed  hy  (bIh  mflmbrane. 

1_ polvpom  eicieecenoe  in. 

{Stt  AUKICLE.) 

Inereasa  oT  cennnen,  cbrooic  and  ac 
DtflcieDcy  of  cenimea. 

All«tntions  in  qualit;  of  cerumen. 

Exanlbetnalons; — Otorrtice*. 

Gonorrhceal  I'Otorrboea. 

Petiaate«l ; — Ulorrhcaa  and  cari 




Affbctions  of  thk  Skix. 

Morbid  Growths,  ani>  Altkba- 
TIONS  Df  Camai. 



Maxjonamt  Dibkasb. 

KczeiiiA  and  herpes. 

Thickening  and  morbid  growth  of  caticle. 






Polypus  and  granulations. 


Morula  and  condylomata. 


Cancer  and  fungus. 



Wounds  amd  Imjurirs. 


i  Wanting. 
Covered  by  false  membrane. 

j  Rupture. 

(  Mechanical  injury. 

Acute,  circumscribed ; — abscess. 

diffused,  Rheumatic. 


Exanthematous ; — Otorrhcea. 

Gonorrhoea! ; — Otorrbosa. 

—  of  mucous  layer ; — Otitis. 




PerforaUon ;  )  otorrhak 

Chronic;  granular; — pannus. 

AxTBRATioxs  IN  CcrncuLAR  Later.  J  Ef^J"*  .*"**. °®'T*®'* 

(  Thickemng  from  pn 

(  Total  destruction ;  { 

Opacitt  akd  Morbid  Dbwwts  «.  \  ^^^  '^f'"'  ^^  'J''*'"'^  '^  ""*••  "'J*'- 

(  Atheruroatous  and  calcareous  deposits. 

Alterations  of  Positioh.  i 

Collapsed  or  flat,  tympanum  open. 

Eustachian  tube  closed. 

from  adbesiooa  in  ^rmpviiim. 


Cohoenital  Malfobxatiohs. 
Woukds  and  Injitribs. 


Cavity  wanting; — (osseous). 

filled  with  morbid  deposit. 

Ossicula  wanting,  irregular,  or  misplaced. 
Fenestns  wanting. 

From  fracture,  or  penetratiiig  inftrament 

DI8KA8B8  OF  THE  CAVITAB  TYMPASI — continued. 


SuImcuU,  CaUrrhil. 

Cbniriic,  with  thickening  of  tbe  roemhrmne, — 

raemiirana  tymiuini  perf^K^t 

tha  caTityvxp)^  from  perfbntion 

M  dMtrnction -of  mcnibranii  tymptni. 
Periosteal  ;~Otitis,  OtoirtusH,  diwan  of  brain. 

PolypoB  and  granutitlona. 

'    0»lBcalion«fl'en< 
Oiteuisrconia,  jiiirl 
Fungus  JiwniBlode). 
Lou  or. 


FoRKtoa  Bouim  n 


Chronic,  witli  thlckeniDg  of  i 
Syphilitic ; — ulcerati  fb. 
I  thidfflncd  and  lelaxed 

WoLMOa  Ana  Ihjubibb. 

Uauo!(a:<t  GROwTHa. 
TuntiTui  AuBiim. 
Kbhvovi  DzaraEss, 


l^yrintli  wanting,  irregular,  or  imperCsctly  do- 

velnped  in  name  of  lb  parts. 
filled  with  caMoui  matur. 

Auditory  nerve  wanting  or  atrophied. 
Fracture,  with  »eronB  or  bloody  effuaion. 


Olitii  \ — Otortlicca ; — cerebral  disesic 

J  Wlfl  cxaltflliijn  ofiieari 
}  Without  cxultatiiiQ  of  ht 

J  From  cerebral  diwase. 


(  From  k 

i  —  di 





AoAtomj  of  the  Aaricnlar  Region :  the  Aniide  and  External  Aaditoiy  CanaL — Congenital 
Malformations  and   Diseaaes  of  the  External  Ear ;  Irregular  or  imperfect  Derdop- 

ment — Wounds  and  Injuries  of  the  Auricle.— Alterations  in  form Morbid  Growtha. 

Inflammations. — Gout. — Cutaneous  Affections :  Eczema,  Herpes,  and  Pemphigaa. — 
Cancer. — Affections  of  Mastoid  and  Auricular  Regions. — Post-aural  Tumours. — Dis- 
ease of  Mastoid  Gland. — Inflammation  of  Periosteum. — Chronic  Abscess. — Aneurism. 
— Caries — Cerebral  Otorrhcea. — Injuries  of  External  Meatus :  Foreign  Bodies  in. — 
Diseases  of  Cerumenous  Glands — inflammations :  Acute,  Chronic,  and  Specific. — Ex- 
ternal Otorrhoea. — Fistula  and  Caries. — Cutaneous  Diseases ;  Piligrowth. — Morbid 
Growths. — Polypus,  Exostosis. — Alterations  in  form  of  Canal Malignant  Diseaaea. 

TT  IS  not  my  intention  to  enter  minutely  or  at  any  length  upon 
■^  the  subject  of  the  anatomy  of  the  organ  of  hearing,  but  sim- 
ply, to  preface  the  description  of  the  diseases  of  each  particular 
part  with  a  brief  sketch  of  the  structures  which  those  diseases 
engage,  in  order  to  revive  in  the  memory  of  the  reader  some  ge- 
neral knowledge  of  the  parts  under  consideration. 

An  ear  consists  of  two  portions,  a  sensitive  and  a  mechanical; 
the  latter  being  generally  subservient  to  the  former,  and  modi6ed 
according  to  the  peculiar  habits,  exigencies,  and  mode  of  life  of 
the  different  classes  of  animals:  in  fishes,  cetacea,  and  amphibians, 
to  inhabit  the  water;  in  birds  and  insects,  to  progress  through  the 
air;  in  moles,  to  burrow  and  seek  their  food  under  the  ground; 
and  in  man  and  other  terrestrial  animals,  to  walk  on  the  earth. 

The  human  ears  are  situated  in  the  temporal  bones,  one  on 
each  side  of  the  cranium.  Each  temporal  bone  consists  of  three 
parts, — the  superior,  thin,  squamous,  or  scale-like  portion,  which 
overlaps  the  frontal  and  parietal  bones  upon  the  temporal  region, 
but  which  is  seldom  engaged  in  aural  diseases;  the  mastoid, 
or  posterior  inferior  part,  thick  and  rough  for  the  attachment  of 
muscles,  and  hollowed  into  cells,  which  communicate  with  the 
cavity  of  the  tympanum,  for  the  purpose  of  increasing  the  surface 


on  which  sound  acts;  and  the  petrous  portion,  so  named  from  its 
stony  hardness,  which  passes  inwards  from  the  junction  of  the 
two  former  to  form  a  part  of  the  lower  arch  or  base  of  tlie  skull; 
besides  various  processes,  the  chief  of  which  are  the  zygomatic 
and  the  styloid.  In  the  petrous  portion  is  placed  the  special  or- 
gan of  hearing.  Anatomists  have  divided  the  ear  into  thiee 
parts:  the  internal,  or  labyrinth,  containing  the  expansion  of  the 
auditory  nerve,  and  including  the  cochlea,  vestibule,  and  semi- 
circular canals;  the  middle,  or  cavitas  tympani,  enclosing  the 
chain  of  ossicles,  bounded  externally  by  the  membrana  tympani, 
and  internally  by  the  outer  wall  of  the  labyrinth,  communicating 
posteriorly  with  the  mastoid  cells,  and  having  an  inferior  exit 
through  the  Eustachian  tube;  and  the  external  ear,  consisting  of 
the  meatus  auditorius  extern  us,  and  the  pinna  or  auricle. 

Viewed  externally,  the  parts  which  become  concerned  in  dis- 
eases of  the  ear,  and  which  may  be  styled  the  aural  region,  are 
contained  within  that  space  between  the  malar  bone  in  front,  and 
the  edge  of  the  occipital  behind,  bounded  above  by  the  attach- 
ment of  the  temporal  muscle,  and  below  by  a  line  drawn  from 
the  angle  of  the  jaw  to  the  lower  margin  of  the  mastoid  process. 
In  the  centre  of  this  lateral  space  of  the  head  is  placed  the  auricle^ 
a  cartilaginous  projection,  varying  in  size,  shape,  and  angle  of 
attachment  in  different  races  of  men,  as  well  as  in  different  indivi- 
duals ;  and  in  the  lower  animals  presenting  all  those  modifications 
applicable  to  their  respective  circumstances  and  habits  of  life, 
with  which  every  one  is  familiar.  The  human  ear  is  an  irregu- 
larly-curved plate,  with  its  concavity  directed  forwards  and  out- 
wards. It  consists  of  the  outer  fold  or  hem  turned  over  on  itself, 
and  called  the  helix,  broad  and  deep  in  front,  where  it  rises 
from  the  upper  boundary  of  the  external  meatus,  and  gradually 
becoming  narrow,  thin,  and  fleshy,  as  it  is  lost  in  the  lobe  be- 
hind and  below.  Its  size,  shape,  and  amount  of  overlapping 
varies  considerably  in  different  individuals,  and  in  many  persons 
this  fold  is  altogether  wanting,  particularly  posteriorly ;  we  also 
frequently  find  in  it  small  hard  nodules.  Within  the  helix  is 
another  elevation,  denominated  the  anti-helix,  of  a  somewhat 
triangular  shape,  arising  in  front  by  two  roots  from  behind  the 


anterior  curvature  of  the  helix.  Curving  upon  itself,  it  forms  the 
superior  and  posterior  boundary  of  the  concha,  and  ends  in  the 
anti-tragus,  a  nipple-like  projection  from  which  the  lobe  depends. 
Between  the  eminences  of  the  helix  and  anti-helix  runs  a  deep 
groove,  called  the  navicular  fossa;  while  the  space  between  the 
roots  of  the  anti-helix  is — after  the  usual  fashion  of  the  old  anato- 
mists, when  they  had  exhausted  their  various  similitudes — called 
the  fossa  innominata.     In  front  of  the  external  auditory  aperture, 
which  it  partially  overlaps,  and  arising  below  the  roots  of  the 
zygomatic  process,  is  a  concave  triangular  projection,  called  the 
tragus,  on  account  of  a  tuft  of  hair  resembling  a  goat^s  beard, 
which  in  some  persons,  particularly  in  advanced  life,  grows  from 
its  tip.     From  the  base  of  the  tragus  being  in  immediate  conti- 
guity with  the  temporo-maxillary  articulation,  it  is  moved  by  the 
action  of  the  jaw,  particularly  in  eating.  The  cellular  and  adipose 
substance  in  front  of  its  anterior  edge  is  often  the  seat  of  inflam- 
mation, and  hence  arises  the  pain  experienced  in  such  cases  from 
any  motion  of  the  lower  jaw ;  and  the  temporal  artery  passing 
through  this  space,  and  there  giving  off  the  anterior  auricular, 
may  account  for  the  unusual  amount  of  throbbing  felt  in  abscess  of 
this  region.    The  largest  concavity  is  the  concha,  which,  leading 
into  the  meatus  in  front,  forms  posteriorly  the  hollow  of  the  ex- 
ternal ear,  and  is  bounded  above  by  the  roots  of  the  helix  and 
anti-helix,  behind  by  the  concave  margin  of  the  latter,  and  below 
by  the  anti-tragus  and  a  gutter- like  fossa,  which  passes  down- 
wards somewhat  in  front  of  the  lobe.     The  concha  is  generally 
capacious  enough  to  contain  the  top  of  the  thumb.     All  these 
eminences  and  depressions,  as  well  as  the  posterior,  inferior,  and  a 
part  of  the  anterior  margin  of  the  meatus,  are  fashioned  out  of 
one  continuous  cartilage,  which  may  be  denominated  the  skeleton 
of  the  car.     Pendant  from  the  lower  edge  of  this  cartilage  is  the 
lobe,  a  fleshy  projection,  more  or  less  long  and  thick  in  difierent 
individuals,  and  passing  ofi* anteriorly  into  the  integuments  of  the 
cheek  beneath  the  tragus.     It  contains  a  quantity  of  cellular  and 
some  adipose  tissue,  and  is  very  extensile,  as  may  be  seen  in  in- 
flammations, dropsy,  and  emphysema,  &c.     From  time  immemo- 
rial, and  among  all  nations,  this  part  has  been  adorned. 


The  caTtilaginous  portion  of  the  ear  is  invested  with  a  strong 
perichondrium,  and  the  whole  is  covered  with  an  envelope  of  fine 
integument,  highly  vascular  and  sensitive,  so  as  to  be  even  sus- 
ceptible of  blushing  and  other  peculiar  impressions  consequent 
upon  mental  emotion.  It  contains  many  sebaceous  follicles,  par- 
ticularly in  the  concha,  where  they  sometimes  become  enlarged, 
and  present  those  dark  worm-like  bodies  with  which  every  one  is 
familiar.  In  some  adults  the  auricle  has  a  thick,  leathery  feel, 
and  it  is  often,  even  in  the  normal  state,  of  a  bluish  purple  colour. 
Even  in  some  new-born  children  we  observe  hair  growing  from 
the  upper  margin  of  the  helix,  and  in  several  hirsute  males  in  mid- 
dle life  this  is  a  common  place  for  tufts  of  hair  to  project  from, 
as  well  as  from  the  anterior  surface  of  the  lobe,  the  tragus,  and 
the  anti-tragus.  The  hairs  growing  from  these  parts  and  around 
and  within  the  external  meatus,  though  short,  are  generally  very 
stiff,  like  the  eyebrows  of  some  aged  persons,  and  often  become  a 
Bource  of  annoyance  either  by  being  entangled  with  the  cerumen, 
or  by  falling  inwards,  and  irritating  the  membrana  tympani. 

The  auricle  is  attached  by  ligaments,  muscles,  and  the  com- 
mon integuments,  to  the  skull,  and  by  dense  ligamen to-cellular 
membrane  to  the  anterior,  inferior,  and  posterior  margin  of  the 
meatus,  extending  from  the  root  of  the  zygoma  to  the  mastoid 
process.  Among  civilized  nations  this  part  is  not  so  well  deve- 
loped, does  not  stand  out  at  the  same  angle  from  the  head,  and 
its  muscular  apparatus  is  not  so  much  called  into  action  as  in 
savage  people,  whose  means  of  safety  or  subsistence  depend  to 
a  certain  extent  on  their  powers  of  hearing.  Any  one  who  ob- 
serves the  ears  of  a  greyhound  when  that  animal's  attention  is 
specially  engaged  may  form  some  idea  of  the  beautiful  muscular 
apparatus  which  an  ear  in  its  natural  condition  possesses.  Still, 
we  often  meet  persons  who  have  the  power  of  moving  the  exter- 
nal ear  in  different  directions,  principally  upwards,  backwards, 
and  a  little  forwards. 

Two  sets  of  muscles  have  been  described  as  belonging  to  the 
human  ear,  but  in  the  great  majority  of  individuals  they  are 
either  rudimentary  or  are  altogether  wanting.  The  first,  or  the 
extrinsic,  are  those  which,  attached  to  the  head,  move  the  exter- 


nal  ear  as  a  whole ;  the  second,  or  the  intrinsic  muscles,  arising 
from  particular  portions  of  the  cartilage,  and  inserted  into  other 
parts  of  the  same  structure,  serve  to  increase  its  various  concavi- 
ties, and  doubtless,  when  well  developed,  they  assist  to  render  the 
external  car  at  particular  times  a  better  collector  and  conductor 
of  sound.  Besides  these  muscles,  certain  fissures,  described  by 
Santorini,  traverse  the  base  of  the  cartilage  near  its  attachment, 
particularly  where  it  forms  the  anterior  triangular  wall  of  the 
flexible  portions  of  the  meatus, — which  are  supposed  to  contain 
muscular  fibres,  capable  of  shortening  that  passage.  It  is  said 
that  the  tyrant  Dionysius  had  a  subterranean  chamber  constructed 
in  the  shape  of  the  human  ear,  which  was  in  connexion  with  an 
adjoining  prison,  and  which  he  employed  for  the  purpose  of  trans- 
mitting whatever  was  said  by  those  confined  therein. 

The  size  and  form  of  the  external  ear  have  been  justly  consi- 
dered characteristic  of  beauty  and  breeding;  and  the  national  pe- 
culiarities of  this  feature  are  not  unworthy  of  attention,  as  also  its 
figure  and  position  in  some  of  the  bygone  races.  Those  familiar 
with  ancient  sculpture  and  painting,  particularly  among  the 
Oriental  monuments,  must  have  observed  many  varieties  of  it 
It  has  been  stated  that  in  the  ancient  inhabitants  of  Egypt  the 
ear  was  placcid  unusually  high  ;  I  have  examined  a  great  number 
and  variety  of  the  crania  of  that  people,  and  I  have  not  found 
the  external  meatus  misplaced;  but  in  the  paintings  and  statues 
the  auricle  appears  to  be  prolonged  upwards.  This  peculiarity  is 
more  noticeable  among  the  Asiatic  races,  strangers,  slaves,  and 
captives,  than  in  the  true  natives  of  the  land,  as  may  be  seen  from 
Rosellini's  faithful  illustrations  of  the  ancient  Egyptian  paintings. 
My  late  esteemed  friend,  the  talented  S.  G.  Morton,  of  Philadel- 
phia, has  given  some  notices  of  the  external  ear  in  his  valuable 
ethnological  writings. 

The  mastoid  region  may  be  defined  as  all  that  semilunar 
space,  for  the  most  part  uncovered  by  hair,  behind  and  partially 
overlapped  by  the  auricle.  Beneath  the  delicate  skin  of  this  part 
we  often  meet  one,  sometimes  two,  small  glands  lying  parallel 
with  the  posterior  attachment  of  the  auricle;  there  is  then  a 
strong  fascia  covering  the  tendinous  expansion  of  the  stemo- 


mastoid  muscle,  and  finally  the  periosteum.  The  posterior-auri- 
cular  branch  of  the  occipital  artery  runs  close  to  the  junction  of 
the  auricle  and  scalp,  and  its  position  should  be  borne  in  mind  in 
making  incisions  in  this  spot. 

The  meatu8  auditorius  extemus  exhibits  greater  variety  in 
length,  shape,  and  direction  than  works  on  anatomy  would  lead 
us  to  believe.  It  is  an  irregularly  curved  tortuous  tube,  wider 
at  the  extremities  than  near  the  middle — from  an  inch  and  a 
quarter  to  an  inch  and  a  half  in  length — ovoid  in  caliber  exter- 
nally, but  becoming  circular  towards  its  distal  end :  and  leading 
from  the  concha  externally,  at  first  a  little  forwards  and  upwards, 
then  backwards  and  inwards,  and  again  turning  downwards,  for- 
wards, and  inwards,  to  the  membrana  tympani,  which  separates  it 
from  the  middle  ear.  Owing  to  the  oblique  position  of  this  mem- 
brane, the  depth  or  curvature  of  the  glenoid  cavity,  and  also  from 
the  cartilage  beneath  being  more  complete,  and  prolonged  infe- 
riorly,  the  roof  of  the  external  meatus  is  somewhat  shorter  than 
its  floor.  It  is  only  by  constant  inspection,  and  also  examining 
a  number  of  casts  of  this  passage,  that  we  can  understand  its 
bearings  and  different  curves.  Independent  of  the  oblique  posi- 
tion from  above  downwards  of  the  membrana  tympani,  there  is  a 
very  well-marked  obliquity  presented  by  the  tympanal  end  of  the 
bony  meatus,  which  spreads  forwards  and  downwards  behind  the 
glenoid  cavity,  where  the  bone  is  remarkably  thin,  and  sometimes 
perforated  with  small  apertures.  It  is  difficult  to  bring  this  por- 
tion into  view  in  the  living  state,  but  it  is  frequently  the  seat  of 
polypus,  which,  when  of  a  small  size,  often  lies  concealed  therein, 
and  keeps  up  discharge  long  after  the  rest  of  the  canal  has  as- 
sumed a  healthy  character.  It  is  best  seen  from  within  by  making 
a  section  of  the  bone  behind  the  groove  for  the  attachment  of  the 
membrana  tympani.  The  bony  meatus  is  about  three-quarters  of 
an  inch  in  length ;  its  outer  margin,  particularly  below,  from  the 
root  of  the  zygoma  to  th^  mastoid  process,  is  rough  for  the  at- 
tachment of  the  auricle,  which  is  fixed  to  it  by  strong  fibro-liga- 
mentous  material.  The  external  third  or  more  of  the  meatus 
auditorius  externus  is  formed  partly  of  cartilage  and  partly  of 
fibro-cellular  tissue,  and  it  is  this  portion  alone  which  is  capable 


of  dilatation  even  to  a  slight  extent,  but  being  suiceptible  of  ( 
siderable  motion,  it  can  be  so  far  straightened  as  to  permit  a  di- 
rect stream  of  light  to  pass  in  through  the  immovable  bonj 
portion  to  the  membrana  tympani.  The  anterior  outer  wall  of 
the  external  meatus,  formed  by  a  triangular  portion  of  cartilage 
within  and  below  the  tragus,  is  influenced  by  the  action  of  the 
condyle  of  the  jaw,  as  may  be  perceived  by  placing  the  point  of 
the  finger  within  the  meatus,  and  then  opening  and  shutting  the 
mouth.  In  cases  of  inflammation  of  the  passage,  the  motion  of 
the  jaw,  as  also  sneezing  or  coughing,  causes  on  this  account  great 
pain  and  distress.  The  parotid  gland  also  coming  up  thus  far,  and 
surrounding  the  lower  and  part  of  the  anterior  wall  of  the  meatus, 
causes,  when  inflamed,  pain  in  the  ear  and  deafness.  The  perios- 
teum and  perichondrium — the  former  of  which  is  remarkably  de- 
licate— are  covered  by  a  reflection  of  the  cutis  from  the  auricle, 
which  is  remarkably  fine  and  vascular  where  it  lines  the  osseous 
portion,  and  its  cuticular  layer  is  reflected  over  the  external 
surface  of  the  membrana  tympani.  This  cuticular  lining  is  sus- 
ceptible of  considerable  thickening  either  by  pressure  or  inflam- 
mation, often  presenting  a  macerated  appearance :  and  in  the  dead 
subject  it  can  sometimes  be  drawn  out  entire,  like  the  finger  of 
a  glove. 

Within  the  external  margin  of  the  passage,  and  in  some  per- 
sons as  far  in  as  the  junction  of  the  osseous  meatus,  there  are  a 
number  of  fine  hairs,  styled  vibrissas,  which,  all  pointing  towards 
the  centre  of  the  canal,  serve  to  exclude  insects  or  extraneous  bo- 
dies, but  which,  in  cases  of  impaction  of  the  canal  with  wax,  act 
like  so  many  nails  to  retain  the  offending  plug  in  situ. 

Imbedded  in  the  integument  of  the  meatus,  chiefly  in  the 
membranous  portion,  and  most  abundant  posteriorly,  we  find  the 
cerumenous  glands  of  Wharton ;  as  a  whole  resembling  a  ring  with 
the  setting  behind, — each  gland  being  somewhat  the  shape  of 
a  Florence  oil-flask.  These  secrete  the  substance  so  well  known 
as  cerumen  or  ear-wax,  of  a  brownish  yellow  colour,  adhesive, 
bitter,  igni table,  composed  of  a  peculiar  animal  matter  resem- 
bling wax,  lactate  of  potash,  and  some  lime.  There  can,  I  think, 
be  little  doubt  that  the  ear-wax  exercises  some  useful  influeiiee 


in  perfecting  the  external  auditory  passage  as  an  acoustic  instru- 
ment, as  well  as  serving  to  exclude  insects.  It  is  frequently 
deficient,  or  altogether  wanting,  in  cases  of  long-continued  deaf- 
ness, so  that  it  is  generally  believed  to  be  one  of  the  causes  of  de- 
fective hearing,  and  various  nostrums  are  still  in  use  for  promoting 
its  secretion.  I  believe  that  the  true  cause  of  its  deficiency  con- 
sists in  inflammation  of  the  glands  from  which  it  is  secreted,  or 
of  the  structures  in  which  they  are  placed.  I  have  examined 
numbers  of  the  congenitally  deaf  and  dumb,  in  whom  the  secre* 
tion  was  quite  abundant;  and  I  have  even  seen  it  accumulate  in 
these  persons,  and  produce  such  uneasiness  as  to  require  removal. 


The  temporal  bone  as  a  whole  is  never,  that  I  have  heard  of, 
wanting,  but  great  variety  exists  with  regard  to  its  different  parts, 
each  of  which  presents  congenital  abnormities,  which  shall  be 
considered  in  detail.  The  external  contour,  particularly  of  the 
squamous  portion,  is  very  variable,  and  seems  to  assume  a  special 
or  fixed  character  in  different  races  of  mankind.  There  is  in  the 
College  of  Surgeons  in  Dublin  the  deformed  skull  of  a  boy  aged  16, 
who,  I  understand,  died  in  one  of  our  prisons  while  under  sentence 
of  transportation,  in  which  the  left  side  is  quite  flat,  and  there  is 
no  trace  of  squamous  suture.  Upon  examining  the  cranium  one 
cannot  help  asking, — Would  not  that  poor  boy  have  been  a  more 
suitable  inmate  for  a  lunatic  asylum  than  a  convict  prison? 

The  auricle  is  not  fully  developed  until  the  sixth  month,  and 
is  that  portion  of  the  auditory  apparatus  most  liable  to  variety 
and  irregularity.  Its  peculiarities  are  sometimes  so  very  slight 
that  those  only  who  are  in  the  habit  of  examining  ears  daily  can 
perceive  any  difference  from  the  normal  condition  of  this  portion. 
The  size  and  shape  of  the  whole  auricle  is  very  various  in  diffe- 
rent families  and  individuals.  The  helix  is,  as  already  stated, 
often  wanting ;  the  lobe  still  more  frequently.  The  concha,  in- 
stead of  being  a  concavity,  is  sometimes  a  convexity.  The  auricle 
is  sometimes  represented  by  a  mere  fold  of  skin ;  I  saw  such  a 
case  in  consultation  with  Dr.  Forrest  some  years  ago ;  it  occurred 
in  an  infant,  and  only  existed  on  one  side.     Instances  have  been 


recorded  of  the  total  absence  of  the  auricle,  yet  it  is  said  the  per- 
sons heard  well.  Schmalz,  in  his  Beitrdge  zur  Gehor  und  SproA" 
Heilkuudej  1846,  has  6gured  three  cases  of  congenital  deformity 
of  the  auricle,  in  the  most  remarkable  of  which  there  was  no  ex- 
ternal meatus,  and  the  upper  portion  of  the  helix  alone  was  nor- 
mal. This  part  has  also  been  found  cleft  A  plurality  of  auricles 
has  been  remarked.  Cassebohm  relates  the  case  of  a  child  with 
four  ears,  two  naturally  placed,  and  two  lower  down  on  the  neck; 
there  were  in  that  instance  two  petrous  portions  to  each  temporal 
bone.  Four  auricles  are  not  uncommon  among  some  of  the  lower 
animals,  swine  in  particular  :  the  old  Irish  pig,  with  long  legs, 
high  back,  and  narrow  snout,  had  very  frequently  supernumerary 
auricles,  small  and  misshapen,  situated  low  down  on  the  neck. 
Sheep  have  sometimes  four  ears.  Professor  A.  Thompson  has 
given  a  '*  notice  of  several  cases  of  malformation  of  the  external 
ear,"  in  the  Edinburgh  Monthly  Journal,  but  his  description  is 
rather  unsatisfactory,  inasmuch  as  in  the  first  case,  that  of  W.  B^ 
the  peculiar  malformation  of  the  auricle  is  not  specified;  in  the 
second  case,  that  of  a  young  lady  at  Falkirk,  she,  he  states,  pre- 
sented **  the  same  kind  of  malformation  to  a  greater  extent  than  in 
W.  B. ;  and  along  with  the  local  malformation  of  the  ear,  consider- 
able imperfection  in  the  lower  part  of  the  face;**  and  in  the  third 
case,  that  of  Miss  R.,  ^*  the  form  of  the  imperfectly  developed 
auricles,  and  the  shape  of  the  countenance,  presented  a  remark- 
able similarity  to  those  of  the  girl  at  Falkirk." — See  Numbers  for 
December,  1846,  and  April,  1847. 

The  same  essay  contains  some  remarks  upon  the  causes  of 
muteism,  which  I  cannot  refrain  from  adverting  to  here.  "  The 
instances,"  he  says,  "  are  extremely  rare,  however,  in  which  deaf- 
dumbness  is  caused  by  congenital  malformation  of  any  kind,  and 
it  is  sufficiently  well  known  to  all  those  who  have  been  connected 
with  institutions  for  the  deaf  and  dumb,  that  in  by  far  the  greater 
number  of  instances  of  deafness,  either  total  or  to  such  a  degree 
as  to  induce  dumbness,  the  affection  has  proceeded  from  diseases 
in  early  life,  such  as  scarlet  fever,  measles,  and  small-pox;  the 
inflammatory  and  suppurative  process  affecting  first  the  cavity  of 
the  tympanum,  and  being  subsequently  communicated  to  some 


part  of  the  labyrinth."  Surely  the  Professor  cannot  have  exa- 
mined any  of  the  works  treating  of  muteism,  or  he  would  have 
been  aware  of  tlie  well-established  fact,  that  in  every  country  in 
which  the  subject  has  been  carefully  examined,  and  faithful  statis- 
tics collected,  the  number  of  the  acquired  cases  of  deaf-dumbness 
is  about  one-eighth  of  the  whole.  A  case  has  been  related  in  which 
the  auricle  consisted  in  a  fold  of  integument  perforated  with  two 
apertures,  and  with  the  concavity  turned  towards  the  head.  The 
auricle  is  sometimes  the  seat  of  congenital  naevus,  either  alone  or 
in  connexion  with  the  same  disease  in  the  neighbouring  parts.  In 
1810  the  late  Professor  CoUes  tied  the  posterior  auris  for  aneu- 
risqi  by  anastomosis  of  the  auricle. 

Congenital  malformations  and  abnormal  peculiarities  of  the 
external  meatus  and  auditory  canal  are  by  no  means  uncommon; 
the  passage  is  frequently  smaller,  and  often  more  tortuous  than 
natural,  and  it  has  been  found  closed  with  a  polypous  excrescence 
at  birth.  There  is  great  variety  in  the  length,  caliber,  and  cur- 
vatures of  the  sides  of  the  external  auditory  passage  among  diffe- 
rent persons, — perhaps  just  as  much  as  there  is  in  the  shape  of 
the  nose,  the  auricle,  or  any  other  feature  of  the  face.  I  had  no 
idea  how  much  diversity  existed  in  the  auricle  until  I  began  to 
study  diseases  of  the  ear ;  and  latterly  I  have  so  frequently  ob- 
served congenital  peculiarities  and  malformations  of  the  auricle 
in  persons  who  have  applied  for  advice  on  account  of  some  aural 
disease,  that  I  have  been  forced  to  the  conclusion,  either  that 
these  peculiarities  occur  much  more  freciuently  than  is  supposed, 
or  that,  in  some  way  which  is  at  present  unaccountable,  persons 
possessing  such  peculiarities  are  more  subject  to  aural  diseases 
than  the  rest  of  the  community. 

I  have  met  with  cases,  both  in  children  and  adults,  in  which 
the  external  auditory  canal  would  not  admit  anything  larger 
than  the  end  of  an  ordinary  dressing-probe.  I  have  also  seen  an 
hour-glass  contraction  in  the  centre  of  the  passage,  which, 
although  it  had  never  impaired  the  hearing,  was  yet  a  consider- 
able impediment  to  the  removal  of  some  hardened  wax  which 
bad  accumulated  behind  it.  The  external  meatus  is  sometimes 
pretematurally  wide.     The  meatus  has  been  found  double ;  the 


siipemumeraiy  canal  opening  behind  the  auricle.  False  mem- 
brancs  stretching  across  the  meatus  have  been  recorded  by  many 
observers ;  and  such  cases  are  susceptible  of  relief  by  surgical  ope- 
ration, although  considerable  difficulty  is  always  experienced  in 
keeping  open  the  newly-formed  aperture.  Several  cases  have 
been  noted  of  imperforate  meatus  with  and  without  any  abnor- 
mal condition  of  the  auricular  cartilage.  Sometimes  the  place  of 
the  external  aperture  is  merely  marked  by  a  slight  depression  in 
the  skin,  at  others  the  membranous  portion  of  the  canal  is  perfect, 
but  beyond  that  all  is  solid  bone.  I  have  met  with  three  ^ck 
cases :  one  was  a  boy  six  years  of  age,  labouring  under  otorrhcea 
on  the  left  side;  upon  the  right  the  membranous  portion  of  the 
canal  was  perfect,  but  the  osseous  part  was  closed  by  firm  bone, 
covered  by  a  thin  layer  of  integument.  The  second  was  in  a 
woman,  aged  30,  born  deaf  and  dumb;  there  was  no  osseous  canal 
on  either  side.     The  third  case  was  as  follows: — 

A  female,  aged  20,  applied  at  the  hospital  on  account  of  otor« 
rhcea  of  the  left  side.  On  examination,  I  found  the  right  auricle 
normal,  but  the  meatus  ended  in  a  shallow  cul  de  sac,  lined  by 
smooth,  white  membrane,  which  just  admitted  the  end  of  the  little 
finger.  She  was  completely  deaf  on  that  side,  but,  strange  to  say, 
until  she  had  the  inflammation  and  otorrhoea  of  the  other,  she 
was  quite  unconscious  of  her  imperfection.  How  frequently  do 
we  meet  with  instances  of  total  blindness  of  one  eye,  evidently 
congenital,  discovered  by  the  merest  accident  long  after  birth. 
Although  the  bottom  of  the  shallow  cavity  in  this  case  felt  and 
sounded  solid,  I  determined  upon  exploring  it,  and  made  upon  two 
occasions  a  crucial  incision ;  but  all  behind  the  membrane,  which 
appeared  to  be  a  thin  layer  of  cartilage  covered  with  fine  int^[a- 
ment,  was  perfectly  solid. 


These  injuries,  either  from  accident  or  design,  are  not  as  fire- 
quent  in  this  country,  nor  indeed  any  other,  as  in  former  days. 
**  Cropping  the  ears**  was,  in  the  time  of  the  civil  wars,  not  an 
unusual  punishment,  and  it  is  still  resorted  to  in  some  Elasteni 
countries.     I  remember  a  baker  in  Cairo  being  nailed  by  the  ear 


to  his  own  door  for  selling  bread  beneath  the  standard  weight. 
The  punishment  was  a  very  severe  one,  as  the  man's  toes  scarcely 
touched  the  ground.  I  suppose  ^*  nailing  the  ear  to  the  pump"* 
was,  from  the  popular  adage,  a  common  form  of  punishment  in 
other  days.  Splitting  or  cutting  off  the  ears  was  a  cruel  mode  of 
maiming  and  ill-treatment  resorted  to  by  the  insurgents  in  this 
country  formerly ;  yet  we  read  in  history  of  celebrated  generals 
forwarding  to  their  sovereigns  the  ears  of  the  vanquished,  as  tro- 
phies of  conquest.  Having  had  an  opportunity  of  examining 
many  of  the  wounded  French  soldiers  after  the  battle  of  Constan- 
tina,  I  was  struck  with  the  number  of  sword-gashes  about  the 
head  and  face,  and  of  the  auricle  in  particular.  I  was  informed 
they  were  inflicted  by  the  yataghan,  the  mode  of  using  which, 
somewhat  after  the  fashion  of  carving  a  round  of  beef,  may  ex- 
plain the  way  in  which  these  wounds  were  inflicted.  In  Germany, 
when  sword  duels  were  common  among  the  students,  surgeons 
had  considerable  practice  in  simple  incused  wounds  of  the  ear. 
Instances  have  been  related  of  adhesion  having  taken  place  even 
after  the  part  had  been  completely  removed.  Writers  seem  to  be 
averse  to  the  employment  of  sutures,  but  we  have  not  in  these 
kingdoms  much  experience  of  the  matter.  The  application  of 
Imt,  spread  with  white  of  egg,  so  as  to  keep  the  parts  in  strict 
apposition,  I  have  seen  used  with  advantage.  A  cork  pad,  accu- 
rately adjusted  to  the  space  between  the  posterior  surface  of  the 
auricle  and  the  mastoid  region,  has  been  recommended,  but  the 
ingenuity  of  the  surgeon  will,  I  think,  without  adhering  to  any 
definite  rules,  generally  enable  him  in  every  case  to  adapt  the 
means  to  the  end.  I  have  seen  the  auricle  lacerated  and  contused 
by  pressure  against  a  wall,  by  falls,  and  by  the  transit  of  a  cart- 
wheel ;  and  in  the  days  of  faction  fights  in  Ireland,  I  have  dressed 
many  dozen  auricles  split  and  bruised  by  blackthorn  sticks,  and 
have  often  wondered  at  the  small  amount  of  injury  or  deformity 
which  follows  such  injuries.  Fracture  of  the  cartilage  has  taken 
place  from  suddenly  and  violently  doubling  up  the  ear. 

The  operation  of  piercing  the  lobe  for  the  introduction  of  ear- 
rings, either  as  a  sanitary  measure,  or  for  ornament,  so  common 
among  all  nations,  is  not  always  unattended  with  unpleasant  con- 


162  nijuRiss  OF  AimicLB. 

sequences.  I  have  seen  it  give  rise  to  erysipelatous  inflammation, 
to  eczematous  eruptions  spreading  over  the  side  of  the  face,  and 
also  to  abnormal  growths  in  the  lobe.  Piercing  is  usually  per- 
formed with  a  sharp  awl  pressed  through,  against  a  cork  held  at 
the  back  of  the  lobe,  by  the  jewellers,  and  those  who  dispose  of 
the  wares,  ornamental  or  medicinal,  to  be  inserted  therein. 

The  skin  of  the  auricle  is,  as  already  stated,  highly  sensitiTe. 
People  speak  of  "  blushing  to  the  ears,"  because  that  part  be- 
comes red  and  hot  upon  mental  emotion.  Besides  this,  there  are 
many  popular  adages  relating  to  this  part.  We  have  all  felt  one 
or  both  ears  unaccountably  hot,  and  apparently  swollen  at  par- 
ticular times.  If  the  left  ear  is  red,  it  is  said  **  somebody  is 
speaking  well  of  you,"*  but  if  the  right,  the  contrary.  When,  ac- 
cording to  the  Mosaic  law,  a  bondsman's  term  of  servitude  had 
expired,  and  that  from  affection  to  his  master  he  desired  to  remain, 
the  owner  was  directed  to  **  take  an  awl  and  thrust  it  through  his 
ear  unto  the  door :  and  he  shall  be  thy  servant  for  ever" — Deut.  xv. 
ver.  17 ; — and  my  friend,  Dr.  Carter,  has  informed  me,  that  when- 
ever a  negro  in  the  West  Indies  wishes  to  attach  to  himself  a  dog, 
he  nails  his  ear  for  a  day  to  the  door-post  of  his  cabin.  The 
state  of  the  auricle  is  said  to  be  characteristic  of  disease  in  other 
organs :  it  is  red  in  congestion  of  the  head ;  livid  in  diseases  of  the 
circulating  system ;  and  cold,  thin,  and  insensible  in  nervous  deaf- 
ness, or  in  diseases  of  the  internal  ear.  Pulling  children's  ears  is, 
I  have  no  doubt,  conducive  to  inflammatory  affections,  both  in  the 
auricle  and  meatus.  Boys  increase  the  angle  of  the  auricle,  and 
give  themselves  what  are  called  "  dog's  ears,"  by  pulling  down 
their  hats  or  caps;  and,  on  the  other  hand,  old  women,  from 
having  tied  up  the  auricle  for  many  years,  have  so  squeezed  and 
flattened  this  part,  that  it  lies  close  to  the  head,  and  the  various 
curvatures,  particularly  of  the  helix,  are  obliterated.  Sloughing 
and  gangrene  may  ensue  from  long-continued  pressure  during  lin- 
gering illness,  or  from  exposure  and  want  of  due  circulation,  as  in 
fever,  when  the  extremities  at  times  mortify. 

Baron  Larrey's  work,  alluded  to  at  page  48,  contains  some 
valuable  observations  upon  wounds  of  the  auricle,  and  the  mode 
of  treating  them.  Among  other  matters  he  mentions  a  case  worthy 


of  consideration  in  a  medico-legal  point  of  view.  An  officer  of 
the  French  army  stated  that  he  was  attacked  by  a  stranger,  who 
cut  off  his  ear,  but  Larrey,  on  examining  the  wound,  discovered 
that  it  had  been  done  by  the  teeth.  He  also  mentions  the  case 
of  a  soldier,  whose  meatus  had  been  grazed  by  a  musket-ball, 
and  the  parts  adhering  subsequently,  the  external  aperture  was 
thus  hermetically  closed  by  the  cicatrix.  As  the  man's  hearing 
remained  perfect,  this  case  attracted  great  attention,  and  he  was 
introduced  at  one  of  the  meetings  of  the  Philomathic  Society,  in 
the  winter  of  1815-16,  as  a  singular  instance  of  the  preservation  of 
hearing  after  he  had  "  lost,  according  to  his  own  statement,  several 
small  pieces  of  the  meatus  itself,  besides  all  the  small  bones  of  the 
ear  P  No  doubt  a  French  soldier  is  a  very  intelligent  person,  but 
whether  his  word  should  have  been  taken  by  the  Savans  with  re- 
spect to  the  loss  of  the  ossicula  auditus  is  questionable ;  and  whe- 
ther the  Baron  should  have  published  the  case  as  a  **  surprising 
circumstance,**  without  having  made  some  attempt  to  explore  the 
state  of  the  membrana  tympani  by  dividing  the  external  cicatrix, 
is  still  more  so.  I  mention  the  case,  however,  in  order  to  show 
the  looseness  which  prevailed  among  medical  writers,  even  of  the 
first  eminence,  with  respect  to  diseases  of  the  ear,  twenty  years  ago. 


Morbid  growHia  of  the  auricle  are  by  no  means  uncommon : 
steatomatous  and  sebaceous  bodies  form  in  the  concha ;  I  have 
three  times  removed  firm,  encysted  tumours,  each  the  size  of  a 
hazel  nut,  from  the  posterior  end  of  the  helix.  Hypertrophy  of 
the  lobe  has  proceeded  to  such  an  extent  as  to  reach  to  the  neck. 
Boyer,  in  his  Treatise  on  Surgical  Diseases,  has  related  the  case 
of  a  large  pendulous  lobe  of  that  description,  which  he  removed. 
The  following  case  of  fibrous  tumour  of  the  lobe,  No.  19  in  the 
Registry,  is  a  good  example  of  its  kind. 

M.  S.,  a  female,  aged  19,  has  a  hard,  firm,  ovoid  tumour,  oc- 
cupying the  centre  of  the  lobe  on  each  side,  but  largest  on  the 
left — of  which  the  accompanying  woodcuts  afford  faithful  repre- 
sentations. It  is  of  a  stony  hardness,  and  is  quite  distinct  both 
from  the  cartilage  above  and  the  fleshy  part  of  the  lobe,  which  it 
appears  to  pass  through.     The  skin  covering  it  is  smooth,  and  of 


1  paler  M 


a  light  pinkish  hue,  like  that  of  a  keloid  tumour.  It  grew  gra- 
dually from  the  orifice  made  for  holding  the  ear-ring,  and  haa  been 
several  months  attuning  its  present 
size.  The  tumour  upon  the  opposite  j»  ^ 
side,  which  also  surrounds  the  hole  /  .jd 
made  for  the  ear-rin|!.  is  much  f 
in  colour,  and  not  larger  than  a 
don  pea.  The  girl  states,  that  she  ex- 
perienced a  great  deal  of  pain  and 
Borcnesi  in  the  wounds  made  in  pierc- 
ing her  ears,  and  that  about  three  or 
four  months  afterwards  she  was  ob- 
liged to  remove  the  ear-rings  on  ac- 
count of  thu  irritation  they  produced. 
The  largo  tumour  was  dissected  out, 
and  the  elliptical  aperture  left  in  the 
lobe  brought  together  with  sutures.  It  healed  kindly,  and  the 
disoosc  did  not  retuin.  This  second  cut  shows  the  shape  of  (he 
tumour  in  profile.  A  section  of  the  tumour 
exhibited  a  dense  yellowish- white  fibrous  ap- 
pearance, and  was  ao  hard  that  the  nail  made 
little  impression  upon  it.  I  saw  this  patient 
about  six  months  afterwards,  and  as  the  ex- 
crescence in  the  lobe  on  the  right  side  had  not  i 
increased,  she  was  nnwillin<;  to  have  it  inter- 
fered with.  Mr.  Williams,  in  his  Treatise  c 
the  Kar,  relates  a  case  of  tumour  of  the  lobe  which  was  removed 
by  Professor  Syme,  and  which,  from  the  description,  would  appear 
to  be  very  similar  to  that  which  I  have  described. 

If  tumours  of  this  description  wore  frequently  to  follow  the  ir» 
ritaiion  caused  by  piercing  the  ears,  we  should  find  them  much 
more  common,  particularly  among  those  nations  who  wear  very 
large,  heavy,  pendulous  ornaments  there ;  but  I  have  frequently 
seen  the  hole  made  to  hold  the  ear-ring  elon<;ated  to  a  slit  three- 
quarters  of  an  inch  long  in  some  of  the  African  and  Oriental 
tribes.  The  South  Sea  Islanders  introduce  pieces  of  wood,  shells, 
and  other  large  Eubstancos,  into  apertures  made  in  the  lobes. 

ivs  tne  snape  oi  tne 


In  a  case  of  goitre,  where  the  tumour  extended  over  the  side 
of  the  neck,  along  the  course  of  the  mastoid  muscle,  which  1  re- 
member seeing  in  the  west  of  Ireland  aome  years  ago,  the  lower 
portion  of  the  auricle  was  enlarged  to  the  size  of  the  palm  of  the 
hand ;  and  we  read  that  pendulous  tumours,  growing  from  the 
external  ear,  are  not  unfrequent  in  those  parla  of  India  where 
goitre  prevails.  Dr.  Graves  has  published  a  case  of  fatty  deposit 
in  the  lobes  ;-7 the  patient  died  subsequently,  and  Dr.  O'Ferrall 
found,  upon  dissection,  a  fatty  degeneration  of  the  liver,  and  fatty 
deposits  in  other  portions  of  the  body. 

J.  E.,  a  male,  aged  24  (No.  18  in  Registry"),  A  tumour,  about 
the  size  of  a  small  pear,  occupies  the  upper  portion  of  the  lefb 
auricle,  between  the  helix  and  the  concha.  It  is  immovable,  has 
a  tense,  clastic  feel,  like  that  of  a  hydrocele,  and  the  skin  cover- 
ing it  is  smooth,  and  of  a  dusky  red  colour.  The  whole  auricle 
is  very  hot,  but  the  pain  is  not  great.  It  is  of  three  months'  du- 
ration, and  baa  been  several  times  lanced  by  a  medical  man,  and 
a  quantity  of  glairy  matter  discharged ;  but  as  soon  as  the  wound 
healed  the  fiuid  re-accumulated.  Hearing  unimpaired.  The  case 
when  admitted  presented  the  characters  shown  in  the  accompany- 
ing illustration. 

A  free  incision  was  made  through 
the  entire  length  of  the  tumour,  and 
about  two  ounces  of  glairy  tenacious 
fluid,  of  a  yellow  colour,  like  that 
contained  in  a  ranula  or  an  enlarged 
bursa,  but  mixed  with  portions  of 
flocculent  matter,  was  discharged. 
The  sac  was  found  to  be  smooth  and 
polished.  The  wound  was  dressed 
from  the  bottom,  with  dossils  of  lint, 
and  a  cold  lotion  was  applied  to  the 
auricle.  Under  this  plan  of  treat- 
ment the  fluid  did  not  again  accu- 
mulate, but  the  auricle  presented 

a  hard,  thickened,  nodulated  feel  and  appearance,  which  remained 
for  months,  and  completely  eflaccd  the  natural  curvatures  and  si- 


nuosities  of  that  portion  of  the  external  ear.  While  the  patient 
remained  in  attendance  at  the  Institution,  he  took  Plummer^s  pill 
and  bark,  and  had  the  thickened  auricle  painted  over  with  tinc- 
ture of  iodine  every  third  day. 

This  is  a  rare  form  of  disease  in  man,  but  I  have  frequently 
seen  it  in  dogs,  when  it  forms  a  hard  lump  attached  to  the  end 
of  the  long  flexible  auricle.  In  one  instance  that  I  rcmembery  it 
caused  so  much  inconvenience  to  a  valuable  pointer,  that  it  had 
to  be  excised.  Mr.  Ogicr  Ward  has  related  cases  of  similar  tumouis 
in  men  and  animab. 


May  occur  idiopathically  or  from  accident.  Simple  phlegmon  is 
not  common  unless  induced  by  the  stings  of  wasps  or  bees,  when 
the  part  swells  to  a  great  extent,  but  it  seldom  requires  treat- 
ment. In  idiopathic  inflammation  the  most  efficacious  treatment 
is  puncturing  with  a  lancet,  and  the  application  of  heat  and  mois- 
ture. The  lobe  occasionally  suppurates,  and  small  boils  frequently 
form  upon  difierent  parts  of  it,  but  their  seat  is  chiefly  round  or 
within  the  meatus,  in  the  consideration  of  which  part  they  will 
be  described.  A  German  physician.  Dr.  F.  Bird,  has  described  a 
form  of  inflammation  peculiar  to  insane  persons,  in  which  the  au- 
ricle swells  until,  in  some  cases,  the  skin  breaks,  and  the  parts  dis- 
charge thick  dark-coloured  blood  and  serum.  Having  no  expe- 
rience of  this  affection  myself,  I  wrote  to  a  number  of  medical 
friends  connected  with  lunatic  asylums,  and  although  their  state- 
ments varied  both  as  to  its  existence  and  cause,  the  establishment 
of  the  disease,  as  affecting  a  particular  class  of  the  community  in 
this  country,  has  been  fully  established.  Dr.  Thumham,  of  the 
Wilts  Asylum,  who  has  had  so  much  experience  on  the  subject 
of  lunacy,  is  of  opinion,  that  the  disease  has  frequently  been  in- 
duced by  injury,  and  that,  consequently,  it  was  much  more  com- 
mon when  restraint  was  extensively  used  than  at  present 

Acute  erysipelatous  inflammation  frequently  attacks  the  auri- 
cle. It,  as  well  as  phlegmonous  inflammation,  may  occur  in  con- 
nexion with  general  otitis,  and  particularly  inflammation  of  the 
external  auditory  canal ;  or  it  may  be  caused  by  the  application 

IM  FLA  KM  AT  IONS  OF  THE  ADRlCUt-  167 

oflceches,  or  by  mechanical  injury.  Generally,  however,  itspreada 
from  the  head  and  face,  in  which  case  a  dep&t  ofmatter  irequentty 
forma  in  the  auricle  aa  well  as  in  the  eyelid. 

Chronic  erysipdaa  is  a  frequent  form  of  disease,  particularly 
among  females  in  advanced  life,  in  this  country.  Generally  spesE* 
ing,  the  patient  hag  first  an  attack  of  acute  erysipelas  of  the  head 
and  face.  The  ear,  from  being  in  such  persons  usually  tied  up 
and  excluded  from  the  air,  does  not  resume  its  natural  healthy  ap- 
pearance along  with  the  other  parts  affected,  and  the  patient  has 
several  repetitions  of  the  disease  in  the  ear  alone,  each  attack 
leaving  the  auricle  more  thickened  and  misshapen,  until  it  be- 
coues  a  hard,  lumpy  mass,  finally  rendering  the  meatus  a  mere 
slit  It  is  a  most  tedious  and  irritating  disease.  The  following 
cate  (No.  23  in  the  Registry)  is,  with  the  accompanying  illustra- 
tion, a  good  example  of  the  affection. 

T.  M.,  a  female,  aged  52,  has  had  frequent  attacks  of  erysipe- 
las of  her  head  and  face  during  the  last  five  or  six  years.  The  ef- 
fects of  the  disease  are,  however,  now  ma- 
nifest only  in  the  external  ears,  but  more 
paiticuiariy  the  left.  The  auricle  is  not 
muOi  enlarged,  but  has  become  hard,  in- 
fieztSIe,  and  resembles  a  piece  of  wet, 
thick  sole  leather ;  its  foses  being  appa- 
rently filled  up  by' subcutaneous  deposit. 
It  is  also  somewhat  shortened  in  its  an- 
tero-posterior  diameter.  The  skin  is  of 
s  dusty  brown  colour,  without  any  exu- 
dationt,  eruptions,  or  crusts  upon  it,  but 
to  the  iect  it  is  lumpy  and  nodulated,  like 
what  we  find  in  certain  forms  of  elephan- 
tiasis; the  lobe  in  particular  presents  this 
thickened  appearance.  The  disease  has  extended  some  way  in 
IroQt  of  the  tragus,  which  ie  also  thickened  and  lumpy ;  and  the 
me&tua  is  nearly  closed, 

Dr.  Kramer  relates  cases  of  "  scirrhous  degeneration"  of  the 
auricle,  but  it  would  appear  that  he  applied  the  term  to  affections 
flimiUr  to  that  now  under  consideration. 


The  treatment  of  acute  erysipelas  of  the  auricle  differs  in  no 
way  from  the  ordinary  rules  for  the  management  of  that  disease 
elsewhere,  and  that  of  the  chronic  form  just  described  is  so  simi- 
lar to  the  treatment  of  eczema  aurium,  given  at  page  170,  that  I 
refer  the  reader  thereto. 

The  various  exanthematous  eruptions  affect  the  external  ear 
as  well  as  every  other  portion  of  the  body.  It  is,  however,  remark- 
able, that  although  the  ear  is  equally  exposed  with,  and  from  its 
situation  more  liable  to,  irritation  from  pressure  than  the  face» 
that  it  is  seldom,  even  in  the  worst  cases,  marked  with  small-pox. 

Gouty  inflammation  of  the  external  ear  has  been  fully  estib- 
lished.  Dr.  Graves,  who  was  the  first  to  describe  this  affection, 
says,  that  the  state  of  congestion  of  the  auricle  seldom  lasts  long, 
and  generally  subsides  on  the  occurrence  of  the  disease  in  the  ex- 

I  do  not  think  that  cliitblains  are  now  as  common  in  this  coun- 
try as  they  were  formerly,  and  perhaps  this  may  be  owing  to  the 
manifest  change  which  has  taken  place  in  our  winter  climate  dar- 
ing the  last  twenty  years.  In  children  and  young  persons  ^o 
suffer  from  these  affections,  the  auricles  are,  from  their  expoied 
position,  particularly  liable  to  be  affected.  In  cold  climates  the 
external  ear  is  constantly  frost-bitten.  During  the  severe  wnter 
of  1840-41  the  hospitals  of  Vienna  presented  numerous  examples 
of  frost-bitten  ^ars.  At  the  same  time  scarcely  a  night  elapsed 
without  a  soldif  r  being  frozen  to  death  at  his  post. 

Enlarged  sebaceous  follicles  frequently  present  in  the  c«ncha 
in  pale,  cachetic  persons  labouring  under  aural  diseases.  They 
are  easily  recognised  by  their  dark  heads,  and  can  be  pressed  out 
with  a  pair  of  forceps. 


Diseases  of  the  skin  of  the  auricle  are  by  no  means  uncommtn, 
and  independent  of  the  irritation  which  they  produce,  they  iray, 
if  allowed  to  extend  into  the  meatus,  produce  disease  in  the  exter- 
nal layer  of  the  membrana  tympani,  and  deafness.  The  most  fine- 
quent  forms  of  skin  disease  in  the  auricle  are  eczema  and  herpes, 


but  diseases  of  the  scalp  do  not  usually  affect  that  organ.  Syphi- 
litic ulceration  is  by  no  means  uncommon,  and  rupise  are  fre- 
quently  seated  on  the  external  ear. 

The  following  case  (No.  22  in  the  Registry)  of  eczema  aurium^ 
with  thickeninGT)  and  closure  of  the  external  meatus  as  a  conse- 
quence  thereof,  is  highly  characteristic : — 

M.  Q.,  a  female,  aged  60,  has  been  deaf,  •*  off  and  on,"  for 
several  years  past,  accompanied  by  noise  and  wandering  pains  in 
her  head,  with  extreme  itchiness  in  the  auditory  passages.  The 
skin  covering  the  auricle,  and  the  scalp  adjacent  thereto,  is  of  a 
fiery  red  colour,  speckled  with  patches  of  yellow,  formed  by  the 
exudation  which  has  collected  in  thin  branny  scales  all  over  it. 
The  parts  are  hot,  and  in  some  places  sticky,  from  a  thin  ichorous 
matter  which  exudes  from  the  surface.  The  auricle  has  lost  its 
natural  shape,  its  folds  and  sinuosities  being  partially  obliterated, 
and  it  has  become  hard,  thickened,  and  lumpy.  The  external 
auditory  aperture  has,  owing  to  the  disease  extending  into  it,  been 
lessened  to  a  third  of  its  natural  size,  and  it  is  filled  with  branny 
scurf.  Upon  removing  the  latter  impediment,  we  can  obtain  but 
a  very  partial  view  of  the  membrana  tympani,  which  appears  to 
be  thickened  and  opaque.  Hearing  distance,  touching.  The  state 
of  the  parts  is  nearly  the  same  on  both  sides. 

In  examining  diseases  of  the  external  meatus  and  auditory 
tube  like  this,  I  find  the  small  silver  instrument,  shaped  like  a  blunt 
gorget,  figured  at  page  55,  very  useful. 

Cases  of  this  description,  and,  like  this,  of  long  standing,  are 
very  hard  to  manage,  because  there  generally  co-exists  some  con- 
stitutional taint,  as  shown  in  the  cutaneous  eruptions  often  mani- 
fest in  other  portions  of  the  skin,  and  because  the  parts  now  under 
consideration  have  become  so  much  altered  in  form  and  texture, 
that  it  requires  a  long  course  of  treatment  to  restore  them  to  their 
natural  condition,  and  thereby  re-establish  their  usual  functions. 
The  disease  principally  occurs  in  females  of  middle  and  advanced 
life ;  but  it  also  happens  to  children  from  six  to  twelve  years  of 
age.  In  the  latter,  however,  it  is  of  a  much  more  active  nature, 
ftt  the  same  time  that  it  is  much  more  amenable  to  treatment.  In 
young  persons  the  eruption  often  co-exists  with  scald  head,  and 


in  both  young  and  old,  if  the  disease  is  allowed  to  exist  for  any 
length  of  time,  it  extends  into  the  meatus,  and  even  over  the  sur- 
face of  the  tympanal  membrane,  which  it  thickens  and  renders 
opaque.  In  old  persons  a  collection  of  branny  scales  accumulates 
in  the  external  tube;  and  in  young  persons  a  thick  creamy  dis- 
charge coats  over  the  lining  of  the  canal  and  the  external  layer 
of  the  mcmbrana  tympani. 

Cleanliness  and  attention  are  indispensable  to  the  eradication 
of  these  affections.  In  the  first  instance,  continual  poulticing  with 
any  emollient  substance  which  keeps  up  heat  and  moisture  ia  ne- 
cessary. Linseed  meal,  boiled  bread  and  milk,  or  well-mashed 
turnips,  will  be  found  useful  applications.  Aflerwards,  when  the 
extreme  heat,  swelling,  vesication,  and  redness,  have  subsided,  a 
solution  of  the  liquor  plumbi,  in  the  proportion  ofa  drachm  to 
the  ounce,  applied  with  several  bits  of  fine  lint,  so  as  completely 
to  envelope  the  auricle,  and  the  evaporation  prevented  by  cover- 
ing over  the  whole  with  a  piece  of  oiled  silk,  rarely  fails  to  lea- 
sen  the  irritation,  and  reduce  the  parts  to  a  healthy  condiuon. 
The  solution  ofgutta  percha  in  chloroform,  lately  introduced 
by  Dr.  Graves  in  the  treatment  of  other  skin  diseases,  I  have 
found  a  very  admirable  remedy  in  the  chronic  form  of  ecxema 
aurium.  The  part  should  be  painted  over  several  times,  until  a 
complete  varnish  has  been  laid  on,  when  the  greatest  relief  from 
the  heat  and  itching  is  experienced.  The  application  should  be 
repeated  from  day  to  day,  as  the  material  soon  begins  to  peel  off, 
but  should  never  be  applied  until  the  acute  attack  has  subsided. 
When  the  auricle  is  shining,  ofa  bright  red,  and  swollen,  punctures 
made  with  the  point  of  a  lancet,  particularly  in  the  helix,  will  give 
great  relief.  In  the  chronic  stage  good  may  be  effected  by  paint- 
ing the  part  with  a  strong  solution  of  nitrate  of  silver. 

But  while  we  employ  these  local  measures,  we  must  not  neglect 
constitutional  means.  Strict  attention  to  diet  should  be  enforced; 
salt  meats,  savoury  dishe?,  and  pastry,  ought  to  be  avoided,  and  a 
sufficient  quantity  of  fresh  vegetables  should  be  consumed  at  din- 
ner. After  the  patient  has  been  well  purged,  a  course  of  Plum- 
mers  pill  may  be  prescribed  with  advantage — at  least,  five  grains 
daily  for  an  adult;  and,  in  a  little  time,  some  of  the  preparations 


of  sarsapariila  administered  in  lime  water  will  hasten  the  cure,  and 
assist  to  eradicate  the  disease  from  the  system.  This  affection  is 
very  apt  to  relapse,  and  we  should,  therefore,  continue  both  our 
local  and  constitutional  remedies  long  after  the  inflammatory 
symptoms  have  subsided.  Old  ladies  think  they  never  can  have 
a  sufficient  amount  of  warmth  about  the  head,  and  it  is  very  diffi- 
cult to  induce  them  to  leave  off  even  one  flannel  nightcap;  but 
we  should  at  least  make  the  attempt,  as  the  head  and  ear  ought 
to  be  kept  as  cool  as  possible.  As  the  swelling  and  inflammatory 
symptoms  subside,  we  should  again  turn  our  attention  to  the  state 
of  the  auditory  tube.  If  any  discharge  exists,  the  meatus  should 
be  syringed  gently  with  tepid  water  daily ;  and  both  it,  the  con-^ 
cha,  and  the  tympanal  membrane,  washed  over  every  second  or 
third  day  with  a  solution  of  nitrate  of  silver  of  the  strength  of  at 
least  twelve  grains  to  the  ounce.  Still  more  advanced  in  the  pro- 
gress of  the  treatment,  when  the  exudation  has  completely  ceased, 
and  the  thickened  cuticle  has  been  quite  removed,  much  benefit 
will  be  derived  from  smearing  over  the  tube  and  membrana 
tympani  with  brown  citrine  ointment  (  Ungt.  Citrinum  Fuscum) 
every  third  or  fourth  day.  It  should  be  applied  in  a  melted 
state  with  a  cameFs-hair  pencil,  and  diluted  by  about  one-third 
of  almond  oil.  This  ointment,  in  which  I  have  great  faith  in 
all  diseases  similar  to  that  now  under  consideration,  should  be 
made  with  either  rape-oil  or  cod-liver  oil,  instead  of  the  olive  oil 
with  the  lard  or  butter  usually  directed  in  the  Pharmacopoeias ; 
it  is  then  of  a  much  darker  colour,  and  never  becomes  hard  or 

*  There  is  no  other  medicine  in  the  whole  Materia  Medica  so  frequently  prescribed  by 
the  practitioner  which  presents  the  same  differences,  both  in  appearance  and  effects,  as  the 
ointment  of  the  nitrate  of  mercury.  Prepared  as  directed  in  any  of  the  Pharmacopoeias 
of  the  three  kingdoms,  it  is  impossible  to  procure  it  alike  in  any  four  different  establish- 
ments. It  is  found  of  all  shades  of  colour,—  straw-coloured,  grey,  green,  yellow,  orange, 
and  of  every  degree  of  consistence,  dry  and  hard,  or  soft  and  pasty.  If  mixed  with  almond 
oil,  as  in  diluting  it  into  an  eye-salve,  it  soon  becomes  green,  and  gets  a  very  unpleasant 
smell,  whether  covered  up  or  not,  and  in  this  state  it  is  often  very  irritating.  Many  apo- 
thecaries in  Dublm  do  not  adhere  to  the  pharmaoopoeial  formula,  but  make  it  up  according 
to  a  form  of  their  own ;  some  use  fresh  butter  instead  of  lard ;  and  others,  difierent  kinds  of 
oil,  as  from  habit  or  experience  they  find  best  On  explaining  my  difficulties,  some  years 
ago,  to  Mr.  Donovan,  he  procured  me  a  citrine  ointment  of  a  very  dark  orange  or  brown 


Besides  those  eczematous  eruptions,  many  other  cutaneous  di8> 
eases  affect  the  auricle,  particularly  in  children.  Excoriations 
take  place  in  infants  behind  the  ears  during  dentition.  There 
is  a  popular  belief  that  they  are  salutary.  Cleanliness  is  their 
chief  cure  when  it  is  advisable  to  heal  them  up. 

We  have  a  disease  in  Ireland — so  prevalent  in  some  counties 
that  it  would  appear  to  be  one  of  our  national  maladies — Pemr 
phxgus  Gangrenons,  first  described  by  the  late  Dr.  Whitley  Stokes^ 
and  of  which  I  have  given  a  description  in  the  medical  memoir 
attached  to  the  Census  of  1841.  So  fatal  is  this  disease  among 
children,  that  no  less  than  17,799  deaths  have  been  attributed  to 
1%  in  ten  years ;  and  as  it  is  a  disease  very  well  known  to  the  lower 
orders,  I  am  inclined  to  think  that  the  amount  has  not  been  ex- 
aggerated. It  goes  under  different  local  names,  but  the  most 
common  are  *•  mortifying  hive,**  *•  burnt  hole,"  and  **  black  ear;* 
the  latter  from  its  so  frequently  appearing  behind  the  ears  and 
upon  the  auricles.  In  the  Irish  it  is  styled  Ithdieadh,  or  the  eating 
disorder,  from  its  phagedenic  character.  The  vesicles,  or  bulls, 
peculiar  to  this  affection,  generally  leave  an  indelible  and  irre- 
gular lace-like  depression,  similar  to  that  of  vaccination. 

Lupoid  and  other  wJiealthy  ulcerations  may  either  commence 
in  the  auricle  or  spread  to  it  from  the  neighbouring  parts.  I  am 
acquainted  with,  and  possess  a  drawing  of,  a  case  of  cutaneous  can- 
colour,  soft,  perfectly  and  equally  smooth,  and  which  docs  not  alter  in  any  way  by  keep* 
ing,  by  exposure  to  light,  by  mixing  with  oiU,  or  even  by  being  gently  heated  to  the 
point  of  fluidity ;  and  it  never  acquires  an  add  smelL  Its  therapeutic  eflfects  I  hav*  had 
long  experience  of,  and  they  are  decidedly  superior  to  those  of  the  dntment  in  mianmi 
use.  Mr.  Donovan  has  not  made  known  its  constituents,  nor  its  mode  of  preparatioo. 
lir.  NichoUs  has  made  for  me  a  citrine  ointment  precisely  similar  in  colour,  aneU, 
consistence,  and  effects,  and  he  informs  me  that  he  usee  rape  oil  instead  of  oliw  oQ,  aad 
does  not  let  the  heat  employed  during  the  preparation  exceed  200°.  Mr.  John  Evans 
has  employed  cod- liver  oil,  and  also  seal  oil,  and  the  preparations  that  produoed  are  ex- 
ceedingly elegant  and  useful  ones.  Mr.  Carroll  likewise  uses  cod-liver  oU  in  the  conpo- 
sition  of  this  unguent.  Messrs.  Bewley  have  obtained  for  me  a  brown  citrine  ointmeDt, 
somewhat  like  those  already  mentioned,  and  they  inform  me  that  it  is  by  naiqg  only  tbe 
very  purest  olive  oil.  I  And  this  ointment  a  decided  improvement  on  the  old  preparatioB, 
and  its  composition  should  be  investigated  by  those  engaged  in  the  prepttratioa  of  aaedi- 
dues  and  pharmacopceias.  When  about  to  be  used,  it  should  be  melted  to  the  r'rwMCtf*^ 
of  cream  by  placing  the  vessel  containing  it  in  hot  water.  It  forms  an  aHnrfTuMff  appli- 
cation in  ophthalmia  tarsi,  as  well  as  in  various  diseases  of  the  ear. 


cerous  ulceration,  extending  from  beneath  the  zygoma,  which  has 
eaten  away  the  tragus,  and  completely  occluded  the  external  mea* 
tus.  It  remained  nearly  stationary  for  many  years ;  sometimes  it 
spread  over  the  cheek,  and  at  other  times  engaged  a  considerable 
portion  of  the  auricle.  Its  progress  has  usually  been  arrested  by 
the  application  of  chloride  of  zinc  In  character  and  appear- 
ance, as  well  as  the  peculiarity  of  the  cicatrix  which  it  leaves,  it 
greatly  resembles  that  form  of  cutaneous  cancer  affecting  the  eye- 
lid described  by  Dr.  Jacob.  Excessively  irritable  sores,  with  hard 
elevated  edges,  frequently  form  on  the  external  margin  of  the 
helix,  but  true  cancer  of  the  auricle  is  very  rare.  Mr.  Travers,  of 
London,  has  recorded  a  well-marked  example,  in  which  he  re- 
moved the  disease.  The  auricle  remained  unaffected  to  the  last  in 
those  cases  of  malignant  fungus  of  the  ear  which  I  have  seen. 


As  I  have  already  remarked  at  page  56,  the  state  of  the  mas- 
toid region  demands  our  most  serious  consideration. 

Tumours  behind  the  ear,  and  in  any  way  connected  with  the 
mastoid  process,  require  the  immediate  and  special  attention  of 
the  practitioner.  Without  entering  too  minutely  into  the  subject 
here,  I  may  specify  six  kinds  of  post-aural  tumours  with  which 
I  am  familiar,  and  the  situation  and  characters  of  which  every 
surgeon  should  be  acquainted  with,  as  some  of  them  may  prove 
fatal  in  either  the  acute  or  chronic  form. 

There  is  a  small  gland  lying  upon  the  mastoid  process  imme- 
diately above  the  insertion  of  the  sterno-mastoid  muscle,  and  on 
a  level  with  the  tube  of  the  ear,  which  sometimes  enlarges  to  the 
size  of  an  almond :  it  becomes  highly  irritable  and  painful  to  the 
touch,  so  as  occasionally  to  resemble  a  neuroma.  It  generally  oc- 
curs in  young  females.  I  remember  one  such  case  which  I  attended 
some  years  ago,  and  it  was  so  painful  that  the  lady  could  not  bear 
to  have  it  touched.  The  external  application  of  iodine,  and  the 
internal  exhibition  of  tonics,  particularly  iron,  will  in  time  remove 
these  tumours,  but  the  cure  is  always  very  tedious. 

The  second  form  of  tumour  is  also  glandular,  and  of  this  I  have 
given  an  example  on  the  next  page.     It  is  simply  a  suppurating 


gland,  and  is  not  unfrcquently  met  with  in  young  children  during 
dentition.  It  generally  appears  in  scrofulous  constitutions^  and 
very  often  in  [)er8on9  who  have  suffered  from  some  inflammatory 
action  in  the  middle  ear  or  the  external  meatus.  Such  was  the 
case  in  the  instance  related  below,  as  I  learned  from  an  inspection 
ol*  the  tympanal  membrane,  as  well  as  from  the  loss  of  hearing.  I 
never  saw  one  of  those  suppurating  glands,  the  great  bulk  of  which 
was  not  below  the  level  of  the  external  meatus,  and  this  is  a  diag- 
nostic of  some  importance,  as  a  very  formidable  and  often  fatal 
swelling,  which  sometimes  occurs  behind  the  auricle,  is  always 
seated  higher  up.  The  treatment  for  this  form  of  tumour  is  ge- 
nerally such  as  was  practised  in  the  case  described. 

A.  II.,  aged  19  (No.  3  in  Registry),  a  grocer*s  shopman,  re* 
siding  in  one  of  the  back  streets  in  an  unhealthy  part  of  the  city, 
applied  at  the  Hospital  on  account  of  a  tumoiur  which  existed  be- 
hind the  right  ear,  and  somewhat  below  the  mastoid  process.  It 
was  about  the  size  of  half  an  orange,  oval  in  shape,  hard  to  the 
touch,  and  of  a  purplish  red  hue,  altogether  very  much  resembling 
the  character  of  a  syphilitic  bubo.  It  did  not  give  the  patient 
much  uneasiness,  and  very  little  increase  of  pain  was  experienced 
on  pressing  it;  he  had  not  had  any  pain  in  the  ear  or  the  side  of 
the  head,  and  he  says  he  never  had  otorrhosa.  The  tympanal  mem- 
brane is  partially  thickened  and  opaque ;  he  heard  the  watch  only 
when  touching.  The  left  ear  was  normal  in  function  and  appear- 
ance. Although  he  stated  that  he  was  in  his  usual  health,  slept 
well,  and  had  his  ordinary  appetite,  he  was  evidently  an  unheal- 
thy subject ;  his  face  was  pallid ;  his  skin  had  a  greasy  aspect;  the 
pulse  was  small ;  and  the  tongue  large,  white,  and  its  margin  much 
indented  by  the  teeth.  He  gave  a  very  unsatisfactory  account  of 
his  disease ;  said  he  never  had  syphilis,  and  bore  no  external  mark 
of  scrofula.  What  was  the  original  cause  it  was  difficult  to  say, 
and  the  patient  appeared  to  be  totally  indifferent  about  his  deaf- 
ness. We  sometimes  find  a  patient  remarkably  apt  and  intelli- 
gent in  all  the  affairs  of  life  who  can  give  but  a  very  meagre 
account  of  the  history  or  symptoms  of  any  disease  under  which 
he  may  labour,  whereas  other  persons  seem  to  be  endowed  with 
a  special  and  often  morbid  taste  for  medical  details,  so  much  so 


that  they  sometimes  neglect  their  ordinary  worldly  concerns  that 
they  may  be  able  to  talk  over  their  complaints  with  any  one  who 
will  listen  to  them.  The  patient  was  directed  to  foment  and  poul- 
tice the  tumour ;  to  avoid  exposure  to  cold,  and  to  take  some  ape- 
rient medicine. 

This  man  did  not  return  to  the  hospital  until  eight  days  had 
elapsed,  as  he  said  the  lump  gave  him  little  or  no  inconvenience, 
and  had  opened  two  days  ago.  It  then  more  than  ever  presented 
the  characters  belonging  to  a  suppurating  gland  in  the  inguinal 
region.  There  was  a  large  irregular  opening,  sufficient  to  admit 
the  top  of  the  forefinger ;  its  edge  was  flabby,  inverted,  and  of  a 
deep  purple  hue.  The  interior  of  the  cavity  was  smooth,  polished, 
and  of  a  dark  red  colour,  totally  devoid  of  granulations,  and  dis- 
charging a  thin  ichorous  matter.  He  had  no  headach,  did  not 
sweat  at  night,  but  thought  his  strength  and  appetite  were  not  so 
good  as  usual.  Simple  dressing  was  applied  to  the  sore,  a  table- 
spoonful  of  bark  mixture  was  ordered  to  be  taken  three  times  a 
day,  and  the  patient  was  recommended  to  remove  some  distance 
into  the  country.  Under  this  treatment  the  man  recovered  per- 
fectly in  a  fortnight. 

The  third  form  of  tumour  I  have  only  seen  upon  two  occa- 
sions ;  it  is  a  chronic  abscess,  very  similar  to  lumbar  abscess,  and 
is,  like  it,  I  believe,  generally  connected  with  diseased  bone.  I 
remember  a  little  boy  at  the  hospital,  about  five  years  ago,  who 
laboured  under  this  disease  upon  both  sides,  and  of  which  I  pos- 
sess a  drawing.  Each  tumour  was  about  the  size  of  half  a  hen- egg, 
fluctuating,  painless,  and  occupying  all  the  bare  space  behind  the 
auricle ;  the  skin  nearly  of  the  natural  colour,  but  traversed  by 
several  blue  veins.  I  opened  these  tumours,  from  each  of  which 
poured  a  quantity  of  the  usual  scrofulous  curdy  matter.  Almost 
the  entire  of  the  surface  of  each  mastoid  process  was  denuded  and 
rough.  The  abscesses  filled  several  times ;  the  child's  health  gave 
way ;  hectic  ensued,  and,  missing  it  for  some  time  from  the  Insti- 
tution, I  made  inquiry  and  was  told  by  the  mother  that  it  had 
•*  died  of  convulsions  caused  by  water  on  the  brain." 

The  fourth  form  of  tumour  is  the  result  of  acute  inflammation, 
either  arising  from  periostitis  of  the  mastoid  process,  and  often 


extending  over  the  entire  parietal  region;  or  caused  by  accuina* 
lations  of  matter  in  connexion  nfilh  the  mastoid  cells,  the  result 
of  disease  spreading  from  the  middle  ear ;  or  it  may  arise  from 
chronic  inflammation  and  otorrhoea  producing  caries.  With  this 
external  manifestation  we  sometimes  meet  with  diseased  action  of 
a  sudden  and  fatal  nature  going  forward  in  the  inner  table  of  the 
skull,  or  within  the  cranium,  in  the  membranes  of  the  brain,  and 
even  the  brain  itself  This  form  of  tumour  should  always  demand 
our  special  attention,  and  the  sooner  we  make  a  free  incision  in 
such  cases,  not  merely  of  the  integuments,  but  through  the  peri- 
osteum down  to  the  bone,  the  better.  Caries  of  the  mastoid  pro- 
cess is  by  no  means  uncommon,  but  its  consideration  properly 
belongs  to  the  description  of  otorrhoea. 

The  iifth  form  of  tumour  is  a  true  aneurism  of  the  posterior 
aural  artery,  of  which  there  is  at  present  a  case  in  Steevens^  Hos- 
pital, under  the  care  of  Mr.  Colles,  who  has  kindly  permitted  me 
to  make  use  of  it. 

A.  F.,  a  female,  aged  27,  states  that  four  or  five  years  ago  she 
perceived  a  buzzing  noise  in  her  right  car,  attended  with  an  occa- 
sional  throbbing  sensation,  particularly  on  laying  her  head  down; 
that  subsequently  she  applied  for  advice,  and  was  syringed  se- 
verely, but  did  not  receive  benefit.  About  eighteen  months  ago, 
she  perceived  a  small,  slightly  pulsating  tumour  behind  the  auri- 
cle, and  having  been  informed  of  the  dangerous  nature  of  it^  she 
lately  came  up  from  the  country  to  have  an  operation  performed. 
The  auricle  is  normal.  On  the  mastoid  region,  occupying  the 
angle  formed  between  the  bone  and  the  back  of  the  auricle,  there 
is  a  pulsating  tumour  the  size  of  an  almond  shell.  It  does  not 
convey  to  the  fingers  the  usual  aneurismal  thrill,  but  upon  the 
stethoscope  being  applied  to  it,  a  well-marked  l/rwt  de  aoti^^l  is 
heard.  Its  external  covering  is  very  thin,  but  natural  in  colour. 
On  compressing  the  artery  with  the  point  of  the  finger,  near  its 
source  behind  the  lobe,  the  tumour  is  immediately  lessened  in  size, 
and  becomes  flaccid,  but  resumes  its  bulk  on  removing  the  pres- 
sure. When  the  sac  is  emptied,  the  bone  beneath  feels  rough. 
The  membrana  tympani  is  normal. 

An  endeavour  has  been  made  to  apply  pressure  by  means  of 


a  pad,  but  owing  to  the  curve  of  the  mastoid  process,  where  the 
posterior  auris  artery  is  given  off  from  the  occipital,  and  the  way 
in  which  it  lies  into  the  angle  formed  between  the  auricle  and  the 
bone,  the  pressure  has  not  been  effectual.  Mr.  CoUes  purposes 
tying  the  artery. 

The  sixth  tumour  which  occurs  in  this  region  is  a  malignant 
fungus,  of  which  I  have  seen  three  cases:  one  in  a  boy  aged  10, 
the  others  in  adults  who  had  passed  50. 

Abscesses  often  form  in  front  of  the  tragus,  and  glandular  swell- 
ings of  the  side  of  the  neck  sometimes  encroach  upon  the  meatus, 
and  impair  hearing.  When  the  fascia  covering  the  parotid,  or  that 
gland  itself,  inflames,  there  is  generally  severe  pain,  throbbing, 
and  tinnitus  in  the  ear,  increased  by  the  motions  of  the  temporo- 
maxillary  articulation.  The  anatomical  relations  of  the  parts,  and 
the  close  approximation  of  the  parotid  gland  to  the  lower  and 
anterior  portion  of  the  external  meatus,  accounts  for  the  amount 
of  aural  pain  felt  in  these  affections,  and  also  in  that  denominated 


These  injuries  are  rare ;  they  are  generally  produced  either  by 
sharp  penetrating  instruments  puncturing  or  lacerating  the  walls 
of  the  passage,  by  extraneous  bodies  forcibly  impacted  therein, 
or  by  the  injudicious  efforts  of  surgeons  to  remove  them.  I  have 
frequently  seen  the  lining  of  the  meatus  lacerated,  bleeding  freely, 
and  subsequently  sloughing  from  rude  efforts  made  to  explore  the 
canal.  After  the  abstraction  of  the  irritating  substance,  the  treat- 
ment of  such  injuries  simply  consists  in  subduing  infliammation, 
and  allowing  the  punctured  or  abraded  parts  to  recover  with  the 
least  possible  degree  of  irritation.  As  in  punctured  wounds  of  the 
orbit,  so  in  injuries  penetrating  the  external  meatus,  or  the  cavity 
of  the  tympanum,  a  guarded  prognosis  should  be  given ;  as  we 
know  not  when  or  where  cerebral  symptoms  will  arise  which  may 
endanger  life. 

Hasmorrhage  from  the  external  meatus  may  occur  from  a  va- 
riety of  causes,  which,  in  a  medico-legal  point  of  view,  it  is  of  consi- 
derable importance  carefully  to  investigate  and  fully  to  understand. 


For  inttance«  a  dead  body  is  found ;  there  is  li»iiorrliage  ficomone 
or  both  ears;  and  medical  evidence  is  required  with  respect  to  the 
cause  of  death.  Now,  haemorrhage  from  the  external  ear  may 
arise  from  strangulation  drowning,  (?),  concussion,  fracture  through 
the  base  of  the  skull,  asphyxia  produced  by  difierent  causes,  apo- 
plexy, and  other  congested  states  of  the  circulation,  as  wellasfidls 
and  blows  upon  the  side  of  the  head ;  but,  although  this  symptom 
is  thus  enumerated  among  the  post-mortem  appearancea,  the  pi6f 
cise  cause  of  the  haemorrhage,  and  the  locality  and  amount  of  lesion, 
have  never  been  fully  detailed.  Bleeding  from  the  external  ear 
may  occur  in  the  progress  of  disease,  from  slight  accident,  or  from 
the  presence  of  polypus,  or  fungoid  granulations  in  the  meatus, 
and  the  amount  of  haemorrhage  is  not  in  proportion  to  the  extent 
of  injury  inflicted.  In  the  same  way,  that  peculiar  ^'  welling  up" 
of  serum — a  well  known  characteristic  of  fracture  of  the  base  of 
the  skull,  passing  through  the  petrous  portion  of  the  tempoial 
bone — has  yet  to  be  fully  explained.  As  the  ear  is  a  part  through 
which  fatal  injuries  might  be  inflicted  without  attracting  the  at> 
tention  of  a  superficial  observer  after  death,  I  do  not  think  the 
subject  of  the  post-mortem  appearance  of  the  ear  has  been  suffi- 
ciently  investigated  by  medico-legal  jurists. 


Foreign  bodies  sometimes  get  into  the  meatus  by  accident,  and 
are  oflentimes,  particularly  among  children,  introduced  by  dengn« 
The  amount  of  pain  and  irritation  which  they  cause  is  exceed* 
ingly  various.  I  remember  being  out  shooting  in  a  plantation 
many  years  ago  with  a  friend,  who,  suddenly  exclaiming,  **  Oh  I 
an  earwig,**  and  throwing  aside  his  gun,  fell  on  the  ground,  mak- 
ing the  roost  piteous  moans,  and  rolling  about  in  convulsive  agony. 
Finding  that  some  small  insect  had  got  into  his  ear,  I  procured 
some  water  from  a  neighbouring  ditch  and  poured  it  into  the  mea- 
tus ;  and,  as  I  watched  for  the  result,  a  little  animal,  well  known 
among  anglers  as  the  hawthorn  fly,  crept  out,  and  the  gentleman 
was  immediately  relieved.  The  fright  experienced  by  the  buning 
of  an  insect  in  the  meatus,  as  well  as  the  pain  and  irritation  which 
it  causes,  can  only  be  appreciated  by  those  who  have  experienced 


that  unpleasantness*  The  little  animal  denominated  the  earwig 
{Fcr/ieula  auricularis)  is  said  to  have  a  peculiar  liking  for  entering 
the  external  meatus,  and  the  Dhor,  or  Dhor-deel  {Gcerim  olens)^  is 
believed  by  the  lower  order  of  Irish  to  be  fatal  if  it  enters  any  of 
the  apertures  of  the  body ;  and  many  of  the  diseases  resulting  from 
coldy  or  affections  of  the  nervous  ^stem  which  follow  sleeping  in 
the  open  air,  are  attributed  to  this  cause.  The  larvss  of  flies  have 
been  found  in  the  external  meatus ;  and  these  maggots,  having 
been  removed,  have  in  time  turned  into  perfect  animals.  To  dis- 
lodge insects  where  they  cannot  be  seen  and  seized  with  an  instru- 
ment, it  is  recommended  to  fill  the  meatus  with  oil,  in  order  that 
their  spiracula,  by  becoming  obliterated,  and  their  respiration 
thus  impeded,  they  may  be  induced  to  creep  out.  This  is  a  very 
good  popular  recommendation,  but  a  little  warm  water  and  a  sy- 
ringe will  probably  prove  a  more  effectual  means  of  dislodgement. 
One  of  the  latest  English  writers  upon  aural  surgery,  having  re- 
commended *'  sweet  almond  oil**  as  the  best  remedy  for  dislodging 
insects,  reminds  me  of  a  quaint,  and  I  rather  think  sarcastic,  pas- 
sage which  I  remember  reading  in  one  of  Boyle*s  papers,  who,  in 
detailing  the  different  cures  said  to  have  been  wrought  by  marrow 
extracted  from  the  thigh  bone  of  a  man  that  was  hanged,  asks 
whether  the  marrow  from  the  thigh  bone  of  any  other  man  might 
not  answer  as  well.  Many  instances  have  been  recorded  of  death 
following  the  forcible  introduction  of  foreign  bodies,  particularly 
splinters  of  wood,  into  the  meatus,  either  by  passing  through  the 
tympanal  cavity  into  the  labyrinth,  or  by  exciting  such  inflammi^ 
Uon  in  the  injured  structures  as,  by  extending  to  the  brain,  in- 
duces disease  in  that  organ.  Peas  and  other  seeds  have  been 
known  to  germinate  by  being  allowed  to  remain  in  the  meatus. 
No.  167  in  ihe  Registry  is  the  case  of  a  boy  eight  years  of  age» 
into  whose  external  meatus  one  of  his  schoolfellows  thrust  a  grain. 
(^Indian  com.  The  schoolmaster,  in  his  wisdom,  endeavoured  to 
remove  it  by  attaching  a  piece  of  wax  to  the  end  of  a  stick,  and 
thrusting  it  into  the  meatus.  After  an  hour's  ineffectual  effort, 
and  the  boy  becoming  almost  convulsed  with  pain,  he  was  brought 
to  a  surgeon,  who  endeavoured  to  remove  the  offending  body  by 
means  of  a  forceps  and  other  instruments.  The  haomorrhage,  how- 



ever,  which  ensaed  wm  so  great  that  it  was  deemed  adTisable  to 
desist  I  saw  the  boj  four  days  after :  a  profuse  fcotid  discharge 
poured  out  of  the  meatus,  on  removing  which  the  walk  of  the 
canal  were  found  to  be  lacerated  and  in  a  sloughing  condition-; 
while  at  the  bottom  of  the  passage  the  grain  of  Indian  oomi  <^a 
yellow  colour,  and  with  several  breaks  and  scratches  upon  its 
smooth  hard  skin,  caused  by  the  instruments  used  to  detach  it, 
was  visible.  The  slightest  touch  of  it  caused  the  most  excruciating 
pain.  With  a  curette  similar  to  that  with  which  I  open  the  cap- 
sule in  extraction  of  the  lens, — its  point  being  bent  nearly  at  a  ri{^t 
angle  to  the  shaft,  introduced  cautiously  between  the  grain  of  con 
and  the  side  of  the  meatus,  and  then  giving  the  instrument  a  half 
turn, — I  succeeded  in  first  twisting  on  its  own  axis,  and  eventually 
bringing  out,  the  grain  of  corn,  which  had,  while  in  the  ear,  in- 
creased to  one-third  more  than  its  natural  size.  Fortunately  the 
membrana  tympani,  although  highly  inflamed,  had  not  been  rup- 
tured, and  the  parts  soon  recovered. 

A  practitioner  brought  a  child  to  my  house,  who,  while  play- 
ing with  some  pebbles,  allowed  a  small  white  stone  to  slip  into  the 
external  meatus  si  x  hours  before.  She  had  not  complained  of  pain ; 
but  the  friends  became  alarmed,  and  were  most  anxious  to  have 
the  pebble  removed,  *'  lest  it  might  get  into  her  brain.**  Hehad, 
he  said,  used  various  instruments,  but  without  success,  to  extract 
or  dislodge  the  pebble.  The  child  appeared  then  in  great  agony, 
and  the  countenance  was  highly  characteristic  of  the  distress  ex- 
perienced. There  was  considerable  haemorrhage  from  the  ear, 
and  the  external  aperture  had  already  begun  to  swell.  Upon  ex- 
amination I  found  the  meatus  extensively  lacerated,  and  could  pes^ 
ceive  and  touch  a  white,  rough  surface  on  its  anterior  wall,  but  as 
I  felt  sure  that  it  was  not  the  offending  body,  but  the  denuded 
bone,  I  recommended,  strongly  against  the  wish  of  my  firiend,  a 
cessation  of  hostilities,  at  least  imtil  the  hssmorrhage  had  ceased. 
A  leech  was  applied  to  the  margin  of  the  meatus,  and  afterwards  a 
poultice  placed  over  the  ear.  Upon  visiting  the  patient  next  morn- 
ing I  found  that  suppuration  had  been  established  during  the  night, 
and  on  syringing  the  ear  with  a  little  tepid  water,  the  white  quarts 
pebble  presented  at  the  external  aperture,  and  was  easily  removed 


with  a  forceps.  Upon  further  examination,  I  found  that  the  mem- 
brana  tympani  had  been  ruptured  anteriorly,  and  that  the  bone 
was  denuded  for  a  considerable  extent  by  the  efforts  made  to  eo^* 
tract  the  foreign  body.  The  parts,  however,  eventually  resumed 
their  natural  appearance. 

Bits  of  slate  pencil,  glass  beads,  cherry-stones,  paper  balls,  and 
such  like  substances,  are  constantly  introduced  into  the  meatus ; 
and  it  is  remarkable,  that  the  amount  of  suffering  is  no  way  com- 
mensurate with  the  size  or  character  of  the  substance  introduced. 
An  intimate  friend  waited  upon  me  late  one  evening  in  a  state  of 
great  anxiety,  accompanied  by  his  little  boy,  who,  he  said,  had 
put  some  glass  beads  into  his  ear  in  the  morning.  On  inquiring 
the  reason  of  his  not  applying  during  the  daytime,  I  was  informed 
that  the  child  had  not  suffered  the  slightest  inconvenience,  and 
had  forgotten  the  circumstance  until  bed-time,  when  he  men- 
tioned it  to  one  of  the  attendants.  The  beads  were  extracted  with 

A  woman  rushed  into  the  hospital  one  morning  in  great  alarm, 
stating  that  a  pin's  head  had  got  into  her  ear,  and  that  several  per* 
sons  had  tried  in  vain  to  extract  it.  On  bringing  every  portion 
of  the  meatus  into  view,  I  was  enabled  to  assure  her  that  her  fear3 
were  unfounded,  when  she  went  away  perfectly  contented,  and 
quite  free  from  the  pain  she  said  she  had  previously  experienced. 

Rude  efforts  made  to  extract  foreign  bodies  from  the  ear  are  as 
likely  to  cause  mischief  as  these  bodies  themselves.  The  simplest^ 
and  often  the  most  effectual,  means  of  removing  small  substances 
firom  the  meatus,  is  by  syringing  the  meatus  with  plain  warm 
water.  If  the  offending  body  is  not  producing  much  pain  or  an- 
noyance, it  is  scarcely  fair  to  the  patient  to  introduce  some  rough 
instrument  into  the  passage,  in  the  hope  of  dislodging  it,  without 
the  use  of  the  .speculum,  and  bringing  the  foreign  substance  well 
into  its  field.  The  operator,  merely  dilating  the  external  aperture 
with  a  divaricating  speculum,  gets  a  glimpse  of  the  offending 
body, — a  piece  of  slate  pencil,  a  small  pea,  or  a  bead, — and  pass- 
ing down  an  ordinary  dressing  forceps,  the  blades  of  which  so  fill 
the  aperture  that  he  must  then  work  by  touch  and  not  by  sights 
attempts  to  seize  the  smooth,  round,  slippery  substance,  which 

188  nrjuuis  of  ths  ksatus. 

10,  at  each  effort,  pressed  down  upon  the  m^nbrana  tTmpani, 
thereby  not  only  eluding  his  grasp,  but  producing  the  moat  ex- 
quisite torture. 

The  head  should  be  placed  against  some  lensting  bodj,  or 
firmly  supported  in  an  operating  chair,  and  the  canal  brongfat  fairly 
within  the  field  of  the  speculum ;  then  the  curette,  or  the  amall 
silver  spatula  figured  below,  acting  either  as  a  lever  or  a  hook, 
will,  if  proper  care  be  taken,  in  almost  every  instance  dislodge 
the  substance;  and  if  it  has  got  into  a  podtion  where  it  cannot  be 
well  got  at,  syringing  will  often  alter  it  so  as  to  present  some  point 
where  it  may  be  either  seized  with  the  forceps  without  pving 
pain,  or  where  we  can  easily  introduce  the  curette  between  it  and 
the  wall  of  the  meatus,  and  so  extract  it  Where  we  employ  a 
forceps,  that  figured  at  page  57,  or  the  one  represented  along  with 
the  spatula  in  the  accompanying  wood-cut,  will  be  found  useAiL 

The  ingenuity  and  dexterity  of  the  operator  will,  however,  sug- 
gest the  most  feasible  mode  of  operating.* 

When  it  is  remembered  that  death  has  firequently  followed 
the  introduction  of  a  foreign  substance  into  the  meatus;  and  that 
epilepsy  and  many  other  distressing  symptoms  have  ensued  from 
the  same  cause ;  and  when  every  practitioner  who  has  met  with 
cases  similar  to  those  detailed  must  have  experienced  some  of  the 
difficulties  to  which  I  have  alluded,  the  foregoing  observations 
will  not  appear  too  long. 

Acids  have  been  poured  into  the  ear  either  by  accident  or 
design,  and  have  produced  frighful  agony,  and  even  death.  How 
far  poisons  act  when  introduced  through  the  meatus  has  not  yet 
been  fully  determined ;  but  the  idea  that  they  induced  fatal  re- 
sults was  current  in  England  in  the  days  of  Shakespeare,  and  still 
prevails  among  the  Irish  peasantry. 

*  TImm  initnuMots  an  itpw— teJ  thiw-fiNirtlia  Uw  natonl 



One  of  the  most  common  and  curable  forms  of  deafness  arises 
from  impaction  of  the  auditory  canal  with  hardened  wax.  In 
cases  of  recent  accumulation  the  dark,  shining,  convex  end  of  the 
plug  may  be  at  once  perceived  on  inspecting  ihe  meatus ;  in  those 
of  long  standing,  where  the  fluid  portion  has  been  evaporated, 
the  offending  material,  mixed  with  hairs  and  scales  of  cuticle,  has 
generally  a  concave  surface,  is  not  polished,  and  is  seldom  so  dark 
as  in  the  former  case.  At  times  the  scale  of  hard  wax  is  not 
thicker  than  a  half-crown  piece,  and  adheres  firmly  to  the  outer 
surface  of  the  membrana  tympani,  causing  impairment  of  hearing 
and  most  distressing  tinnitus. 

Gases  of  deafness  proceeding  from  accumulation  of  cerumen 
are  so  numerous  and  so  easy  of  cure  that  it  seems  unnecessary  to 
occupy  space  in  describing  them,  while  so  many  other  diseases  of 
the  ear  present  themselves  more  worthy  of  our  attention,  because 
less  known  and  more  difficult  to  treat.  Yet  let  me  say  that  the 
ability  of  making  a  diagnosis  in  such  cases  is  not  always  possessed 
even  by  good  surgeons  and  physicians.  From  week  to  week 
I  meet  with  cases  of  deafness  attended  with  tinnitus  aurium, 
which  have  been  ascribed  to  and  treated  as  depending  upon  func- 
tional or  organic  derangements  of  other  organs,  the  stomach  and 
the  brain  in  particular,  and  for  which  constitutional  means  as 
well  as  topical  applications  had  been  employed  at  considerable 
length,  but  which,  upon  examination,  proved  to  be  nothing  more 
than  firmly  adhering  pieces  of  hardened  wax. 

A  medical  friend  in  the  country  wrote  to  me  to  say  he  had 
become  suddenly  deaf  in  one  car ;  that  he  applied  to  a  neigh- 
bouring surgeon  who  syringed  him  ^*  for  a  long  time ;"  that  only 
a  little  wax  came  out;  whereon  he  had  taken  aperient  medicine, 
filled  the  meatus  with  cotton  steeped  in  brandy,  and  applied  a 
blister  over  the  mastoid  process.  As  I  could  not  possibly  advise 
him  what  to  do  without  knowing  what  was  the  cause  of  his  deaf- 
ness, or,  at  least,  having,  by  means  of  ocular  inspection,  a  certain 
amount  of  positive  and  negative  symptoms  to  judge  firom,  he 
came  to  town,  when  I  found  a  layer  of  hard  dark  wax  pasted  over 


the  membrana  tympani,  which  was  easily  lifted  off  with  aspatala, 
but  which  no  syringing  would  have  removed.  All  his  symptoma 
immediately  disappeared. 

If  we  examine  the  membrana  tympani  after  the  offending  sub- 
stance  has  been  removed,  we  will  in  most  cases  find  it  vascular, 
and  the  lining  of  the  canal  pinkish.  To  judge,  however,  from 
this  state  would  be  most  erroneous,  as  the  irritation  produced  by 
the  removal  of  the  wax  necessarily  gives  rise  to  the  vascular  cob* 
dition  alluded  to.  Persons  who  perspire  much  about  the  head 
seem  to  be  more  liable  than  others  to  collections  of  cerumen. 

Unless  illuminated  by  some  means,  natural  or  artificial,  the 
external  auditory  passage  is  a  dark  cavity,  and,  without  proper 
inspection,  it  is  not  possible  to  know,  by  any  set  of  symptoms  of 
which  the  patient  himself  is  conscious,  whether  his  disease  pro- 
ceeds from  the  simple  mechanical  impediment  of  a  plug  of  wax, 
disease  of  the  middle  ear,  or  threatenings  of  serious  mischief  in 
the  brain  itself,  because  the  two  most  prominent  symptoms, 
deafness  and  tinnitus  aurum,  are  common  to  all  three,  and  to 
many  other  diseases  of  the  ear  also ;  in  the  same  manner  as  we 
find  impaired  vision  and  muscse  common  to  so  many  diaeasea  of 
the  eye,  as  well  as  symptomatic  of  cerebral  and  other  affections. 
I  see  few  cases  of  incipient  cataract  in  the  upper  ranks  of  life 
which  have  not  already  undergone  a  little  doctoring,  under  the 
impression  that  the  disease  depended  upon  the  state  of  the  sto- 
mach ;  and  blue  pills,  bitter  mixtures,  and  dietetic  regulations^ 
have  had  full  sway.  But,  where  so  much  has  been  achieved  for 
medical  science  during  the  last  twenty  years  by  greater  attention 
to  diagnosis,  thus  rendering  the  healing  art  a  moro  accurate 
science  than  heretofore,  I  do  not  think  it  is  too  much  to  ask  the 
practitioner  to  possess  himself  of  a  small  tubular  speculum,  and  to 
take  a  peep  at  the  state  of  the  parts  he  is  prescribing  for,  before 
he  resorts  to  the  routine  treatment  alluded  to.  This  is,  properly 
speaking,  one  of  the  errors  of  omission.  Now  I  will  state  one 
of  commission.  A  patient  is  seised  with  deaftiess  and  a  singing 
noise  in  one  of  his  ears.  The  medical  attendant,  supposing  it  might 
be  wax,  squirts  hot  water  with  a  powerful  syringe  into  the  audi- 
tory passage  for  half  an  hour  together,  and  as  nothing  cornea 


oat,  he  syringes  the  harder.  All  this  time  the  patient  laboured 
under  inflammation  of  the  drum  of  his  ear,  which,  I  need  not 
say,  was  not  improved  by  the  treatment  adopted.  Let  me  entreat 
of  my  readers  never  to  syringe  an  ear,  nor  to  drop  any  stimulating 
application  into  it,  until  they  have  carefully  examined  the  state 
of  the  parts,  and  assured  themselves  of  the  presence  of  wax  or 
other  foreign  body.  My  advice  was  sought  by  an  officer,  for 
deafness  caused  by  thickening  of  the  membrana  tympani.  On 
asking  his  medical  attendant  what  treatment  he  had  employed, 
he  said,  *'  I  syringed  him  every  day  for  three  weeks,  but  nothing 
came  out**  I 

The  cerumenous  glands  are  more  liable  to  morbid  changes 
than  the  profession  are  aware.  The.  moment  an  inflammation  is 
set  up  in  the  neighbouring  structures  they  cease  to  secrete.  When 
otorrhosa  is  present,  their  function  seems  also  suspended.  At 
times  they  secrete  a  thin,  light-coloured,  honey-like  cerumen, 
so  quickly  and  in  such  quantity  as  to  pour  out  of  the  external 
meatus.  This  I  have  chiefly  seen  in  weakly  females,  and  often 
occurring  as  a  sequel  to  some  febrile  attack.  It  is  the  analogue  to 
inflammation  of  the  Meibomian  glands.  From  children  of  a  year 
old  to  persons  of  extreme  age  we  meet  with  collections  of  hard- 
ened wax  in  the  ear,  and  are  called  upon  to  remove  them ;  but 
they  are  more  frequently  seen  in  middle  life  than  at  any  period 
antecedent  thereto.  They  are  not  always  accidental,  as  we  learn 
firom  the  same  person  returning  again  and  again,  at  intervals  of 
two  or  three  years,  to  have  them  removed.  The  vitiated  secretion 
probably  depends  upon  some  chronic  inflammation  of  the  ceru- 
menous follicles  themselves.  The  wax  is  generally  darker  in 
colour  than  natural,  at  times  resembling  pitch  in  its  tenacity  and 
hue.  In  other  cases,  it  becomes  as  hard  as  a  piece  of  mortar  or 
concrete,  and  forms  an  accurate  cast  of  the  meatus  auditorius  ex- 
temus,  feeling  to  the  touch  of  an  instrument  like  a  stone  or  foreign 
body.  As  soon  as  this  has  occurred  hearing  is  much  impaired ; 
but  from  time  to  time  the  patient  feels  a  slight  report  in  his  ear, 
particularly  afler  eating  or  moving  his  jaws,  and  then  the  hearing 
is  much  improved  for  a  short  period.  The  improvement  is  caused 
by  the  motion  of  the  external  portion  of  the  tube  slightly  disad- 


justing  the  cork  of  wax,  and  so  allowing  air  and  sound  to  be 
temporarily  transmitted  to  the  dnim*head;  but  the  improTiraiieDt 
is  lost  as  soon  as  the  plug  has  regained  its  former  poeitiout  or  an 
additional  deposit  of  wax  fills  up  the  space,  and  again  oodndes 
the  air  and  sound.  This  circumstance,  triyial  as  it  is,  is  worthy 
of  note,  because  something  very  similar  takes  place  in  another 
disease  of  the  ear,  arising  from  a  totally  different  cause.  In 
catarrhal  inflammation  of  the  middle  ear,  with  thickening  of  the 
lining  membrane,  or  mucous  collections  within  the  Eustachian 
tube,  or  thecavitas  tympani,  we  perceive,  as  perhaps  many  of  m 
have  ourselves  experienced  when  labouring  under  catarrh  or  in- 
fluenza, a  sudden  report,  as  if  something  gave  way  in  the  ear,  fol- 
lowed by  an  immediate  accession  of  hearing.  In  some  eases  of 
complete  impaction  of  wax,  particularly  where  it  is  very  bard  and 
of  long  standing,  the  patient  does  not  hear  the  watch,  even  when 
held  to  the  auricle,  pressed  agunst  the  mastoid  process,  or  laid 
upon  the  forehead — symptoms  generally  indicative  of  some  grest 
lesion  of  the  internal  or  middle  ear,  or  paralysis  of  the  auditoiy 
nerve ; — ^yet  as  soon  as  we  have  removed  the  mechanical  impedi- 
ment, the  hearing  becomes  exalted  to  a  degree  which  is  painful 
to  the  patient  to  bear.  I  cannot  but  think  that,  in  such  oases, 
the  loss  of  power  has  arisen  from  the  pressure  exerdsed  by  the 
foreign  body  upon  the  tympanal  membrane,  and,  through  it| 
transmitted  by  the  chain  of  ossicula  to  the  labyrinth. 

Squirting  hot  water  into  the  auditory  passage,  even  with  the 
most  powerful  syringe,  will  not  always  succeed  in  removing  the 
ofiending  body.  In  fact,  if  not  properly  done,  it  rather  increases 
the  impaction.  I  have,  however,  seldom  met  a  case  in  which, 
with  a  little  care  and  patience,  I  could  not  remove  the  wax  at  one 
sitting.  One  of  the  cases  which  proved  an  exception  to  this  was 
in  a  person  who  had  a  natural  hour-glass  contraction  in  the  mid- 
dle of  the  passage,  and  another  where  there  was  an  exostosis 
the  size  of  a  split  petk  in  the  same  locality.  The  best  syringe 
to  employ  is  that  figured  at  page  77,  worked  with  the  right 
hand,  while  the  led  grasps  the  top  of  the  helix,  and,  by  drawing 
it  slightly  upwards,  outwards,  and  backwards,  assists  to  straighten 
the  meatus,  and  thus  facilitate  the  exit  of  the  plug  of  hardened 

DI8BA8B8  OP  THE  OEBUHXironS  OUSDS.  187 

cerumen.  The  jet  of  fluid  should  not  be  directed  point-blank 
against  the  cork  of  wax,  but  rather  to  its  edges,  -where  it  is  at- 
tached by  a  number  of  hairs,  and  is  often  intimately  united  with 
the  cuticle.  From  time  to  time  we  should  introduce  the  specu- 
lum and  see  what  progress  is  being  made.  The  fine  long-bladed 
forceps  may  sometimes  be  slipped  down  upon  the  ofiending  body, 
and  it  can  be  thus  withdrawn ;  or,  what  I  find  much  more  useful, 
the  small  silver  spatula  already  described,  and  which,  acting  as  a 
lever,  moves  the  plug,  and  so  allows  the  water  to  get  behind  it 
and  force  it  out  Another  instrument  very  useful  in  such  cases 
18  a  fine  blunt  curette,  made  of  silver,  and  with  the  end  bent 
for  about  a  line  in  length  at  a  right  angle  with  the  shaft,  referred 
to  at  page  179.  By  slipping  this  down  between  the  cork  of  hard 
wax  and  the  wall  of  the  meatus,  and  then,  when  it  has  proceeded 
some  distance,  giving  it  a  half  turn,  so  that  its  point  fixes  in  the 
plug,  the  latter  may  often  be  removed  en  masse.  Care  must,  how- 
ever, be  taken  in  using  these  little  instruments  not  to  abrade  the 
akin,  which  at  the  lower  portion  of  the  meatus  is  very  delicate, 
and  apt  to  bleed  upon  the  slightest  irritation.*  We  read  in  books 
on  aural  surgery,  and  in  lectures  and  details  of  cases  given  in  pe- 
riodicals, of  various  substances  employed  for  the  purpose  of  soften- 
ing wax — the  last  of  which  was  glycerine ;  but,  if  attention  is  paid 
to  the  directions  I  have  now  given,  some  patience  exercised,  and 
that  we  proceed  with  care  and  delicacy,  I  do  not  think  we  need 
often  have  recourse  to  any  of  the  nostrums  recommended  for 
softening  and  removing  wax.  Should  we,  however,  at  first  en- 
counter any  difficulty,  or  the  patient  experiences  much  pain  from 
our  manipulation,  it  is  better  to  desist,  and  drop  a  little  warm  oil 
into  the  ear  once  or  twice  a  day,  or  keep  a  bit  of  cotton  moistened 
with  oil  in  the  passage,  until  the  wax  has  been  partially  softened. 
Simple  removal  of  the  wax  will  generally  restore  the  hearing 
at  the  moment,  but  the  tinnitus  oft;en  remains  for  some  time  after. 
As  a  consequence  of  impaction  of  the  auditory  passages  with  ce- 

*  The  ear-pan  fignied  at  page  76  will  be  fbnnd  a  yeiy  oonyenient,  cleanly  inatru- 
BMBt  I  have  latterlj  placed  the  perforated  division  acrois  one  end  instead  of  along  die 
length  of  the  paOk 


rumeny  producing  thiokeninff  of  the  cuticolar  layer  of  the  mem- 
brana  tympani,  the  two  following  Cases  may  be  cited: — 

L.  W.,  a  male,  aged  40  (No.  14  in  the  Registry),  applied  on 
account  of  deafness  in  his  left  ear  of  some  weeks*  standing,  but 
which  had  recently  increased  very  much.  Complains  of  noiae  like 
that  of  a  boiling  kettle.  Hearing  distance,  two  inches;  says  it 
varies  from  time  to  time,  but  that  it  was  always  better  after  eating 
until  lately.  Occasionally  he  experiences  a  loud  noise,  as  if  a  report 
took  place  in  his  ear,  after  which  the  hearing  is  improved.  £Bs 
disease  has  been  of  twelve  months*  standing.  Upon  examination,  I 
found  the  external  auditory  passage  filled  to  its  aperture  with  hard, 
brownish,  inspissated  cerumen.  It  is  so  hard,  that  percussion  with 
a  probe  conveys  the  sensation  to  the  fingers  as  if  stmck  against  a 
body  as  firm  and  resisting  as  stone.  Numerous  short  but  firm  haiis 
grow  around  the  external  aperture,  and  some  of  the  more  internal 
ones  are  probably  mixed  up  with  the  hardened  cerumen,  and  so 
assist  to  keep  it  immoveably  fixed  in  its  place.  The  mere  projection 
of  a  stream  of  warm  water  from  a  syringe  will  not  easily  remove 
such  a  thoroughly  impacted  mass  as  this.  It  must  be  assisted  out 
with  the  spatula,  slightly  bent  at  the  end,  like  the  old  lever  used 
in  midwifery ;  but  the  ear  should  be  syringed  from  time  to  time 
as  we  proceed  with  our  manipulations.  When  well  loosened,  I 
removed  it  en  masse  with  a  pair  of  fine  forceps,  and  perceived  that 
with  it  came  out  a  large  collection  of  hairs,  which  had  become 
entangled  within  it;  and  that  all  its  lower  portion  and  its  extre- 
mity was  covered  over  with  a  layer  of  soft,  white,  thickened  cu- 
ticle, the  natural  lining  of  the  surface  with  which  it  has  been  so 
long  in  contact,  thickened  and  separated  by  the  pressure  exercised 
upon  it  by  this  foreign  body.  Immediate  relief  to  all  the  symp- 
toms under  which  this  person  laboured  was  experienced  by  the 
removal  of  the  foreign  substance.  The  hearing  increased  to 
twelve  inches,  and  the  noise  lessened  considerably.  Upon  inspec- 
tion through  the  speculum,  the  membrana  tympani  was  seen 
whitish  and  succulent,  and  having  the  parboiled  appearance  of 
the  piece  of  cuticle  which  had  been  removed  from  it.  Several 
large  red  vessels  also  ramified  upon  its  surface,  and  coursed  along 
the  insertion  of  the  malleus  in  particular.     This  condition  wa^ 


no  doubty  caused  by  the  pressure  of  the  accumulated  and  hardened 
cerumen ;  but  in  a  few  days  the  part  recovered  its  natural  cha- 

Several  times  during  the  removal  of  this  wax  the  patient  was 
seized  with  a  fit  of  spasmodic  coughing,  apparently  caused  by 
some  irritation  in  the  larynx.  I  have  already  alluded  to  this  pe- 
culiar phenomenon  at  page  77.  Since  that  portion  of  this  work 
was  printed,  I  met  the  following  observations  in  the  British  and 
Foreign  Medico-Chirurgical  Review,  vol.  xvii.,  p.  414: — 

'*  Pruritus  of  the  external  meatus  auditorius,  from  hyperaes- 
thesia  of  the  auricular  branch  of  the  pneumogastric,  is  sometimes 
observed,  and  is  accompanied  by  cough  and  vomiting.  This  con- 
nexion between  the  car  and  the  stomach  and  lungs  is  not  suffi- 
ciently remembered  by  modem  practitioners.  Arnold  mentions 
an  interesting  example  of  chronic  vomiting  in  a  child,  which 
long  resisted  all  curative  means,  but  which  was  effectually  re- 
moved by  removing  a  bean  from  each  of  the  child's  ears  that  had 
slipped  in  while  at  play.  Cassius  Medicus  has  for  one  of  his 
problems, — Why  does  irritating  the  ears,  as,  for  example,  with 
a  speculum,  cause  sometimes  a  cough,  just  as  if  the  trachea  was 

No.  5  in  Registry,  M.  B.,  aged  25,  a  literary  teacher,  com- 
plained of  general  deafness,  with  singing  noise  in  both  ears.  Upon 
inspection,  the  external  auditory  passages  were  found  to  be  corked 
up  with  hard  inspissated  cerumen.  This  was  removed  by  syringing 
with  warm  water  in  the  ordinary  manner,  upon  which  the  hearing 
was  quite  restored  in  the  right  and  partially  in  the  left  ear.  A  few 
days  having  been  allowed  to  elapse,  in  order  that  the  meatus  and 
external  surface  of  the  tympanal  membranes  might  regain  their 
ordinary  appearance  after  the  vascularity  produced  by  the  pressure 
of  the  wax,  and  the  excitement  and  irritation  caused  by  its  remo- 
val had  subsided,  this  case  was  again  examined. 

Right  Ear. — Hearing  distance,  two  feet  and  a  half;  the  mea- 
tus dry,  but  no  appearance  of  disease  presented  upon  inspection 
with  the  speculum. 

Left  Ear. — Hearing  distance,  four  inches ;  walls  of  meatus  co- 
vered with  flakes  of  thickened  whitish  cuticle,  which  presented 

190  IVfIi4]fHATI0St  or  THB  IZTSUUL  MB4Tm. 

the  Appeanmoe  of  partial  maoeimtioii,  and  neaily  filled  up  tbe 
vity.  Upon  removing  these  with  a  forcepa,  the  saifiu^e  beneath 
presented  a  florid  red  coloor.  The  membrana  tympani  was  thick- 
ened throughout,  and  exhibited  patches  of  vascularity,  which  deep- 
ened into  a  continuous  red  surface  above  and  behind  the  inaerUaa 
of  the  malleus.  He  had  a  confused  rustling  noise  in  this  ear.  The 
Burhce  of  the  meatus  and  the  membrana  tympani  was  washed 
over  with  a  solution  of  nitrate  of  silver,  five  grains  to  the  ounce; 
a  dose  of  aperient  medicine  was  prescribed  for  him,  and  he  was 
directed  to  wear  a  bit  of  cotton  wool  in  the  external  aperture,  so 
as  to  exclude  the  cold  air.  In  ten  days  this  case  was  again  in- 
spected. Tbe  meatus  on  the  left  side  had  resumed  its  natuial 
colour,  but  was  very  dry  and  somewhat  scaly.  The  tympanal 
membrane  had  cleared  considerably  since  last  report;  the  lower 
portion  in  particular  had  become  quite  free  from  vascularity,  but 
a  few  large  vessels  could  still  be  observed  coursing  behind  the 
manubrium.  He  could  inflate  the  tympanal  membrane  after  the 
manner  described  in  the  former  cases.  The  hearing  distance  had 
increased  to  fourteen  inches;  the  noise  had  very  much  lessened, 
and  occasionally  intermitted  altogether.  The  surfiu^e  of  the  mem- 
brana tympani  was  again  washed  over  with  the  soluUon  of  caustic, 
and  the  walls  of  the  meatus  smeared  with  brown  citrine  ointment, 
applied  in  a  melted  condition. 

The  chronic  inflammation  of  the  entire  external  auditory  apei^ 
ture  in  this  case  appears  to  have  been  the  result  of  mechanical  pres- 
sure, and  the  irritation  of  the  hardened  wax. 


Inflammations  of  the  external  meatus  and  auditory  canal  are 
of  very  common  occurrence.  To  follow  out  the  anatomical  prin- 
ciple of  classification  pursued  by  some  authors,  these  inflammations 
should  be  divided  according  to  the  structure  in  which  they  have 
their  seat;  but,  as  all  practical  surgeons  are  well  aware,  it  is  no 
more  possible  to  do  so  than  it  is  to  limit  the  spread  of  these  in- 
flammations. Thus,  what  may  commence  as  a  simple  inflamma- 
tion of  the  tegumentary  tissue,  may  end  in  caries  of  the  bone  and 


inflammation  of  the  brain  or  its  membranes.  I  have,  thereforei 
adopted  the  arrangement  specified  in  the  nosological  chart,  and  of 
which  the  following  is  a  description : — 

Abscess  in  the  external  meatus  is  one  of  the  most  painful  and 
firequent  inflammations  of  the  external  ear.  Grenerally  it  is  not 
like  the  difiused  form,  the  result  of  cold,  but  seems  to  be  induced 
by  some  peculiar  state  of  the  constitution,  and  very  often  appears 
either  as  the  sequel  to  or  a  concomitant  of  boils  on  other  parts  of  the 
body,  particularly  about  the  neck.  These  abscesses  are  more  fre- 
quent in  females  than  in  males ;  and,  I  am  inclined  to  think,  appear 
oftener  in  persona  of  the  upper  walks  of  life  than  those  in  the  lower. 
They  may  be  seated  anywhere  all  round  the  external  meatus,  but 
occur  more  frequently  in  the  anterior  and  posterior  wall  than  in 
the  roof  or  floor.  They  may  not  exceed  a  pea  in  size,  or  they  may. 
advance  to  that  of  a  large  marble,  or  even  a  walnut,  when,  if 
seated  anteriorly,  they  spread  in  front  of  the  tragus,  and  if  poste- 
riorly, they  present  a  considerable  protuberance  over  the  mastoid 
process,  so  as  to  be  distinguished  with  some  difficulty  from  in- 
flammation, and  deposits  of  pus  beneath  the  periosteum  in  that 
situation.  They  seldom  or  ever  appear  singly :  there  is  generally 
a  succession  of  them,  and  of  this  the  patient  should  be  informed 
on  first  applying  for  advice.  There  is  not  much  redness  of  the 
part;  the  heat  is  more  of  a  burning  or  itching  character.  The 
pain,  however,  is  most  intense,  aggravated  by  the  slightest  touch, 
and  always  increased  at  night,  and  also  by  any  motion  of  the  jaw. 
In  addition,  there  is  always  more  or  less  tinnitus,  and  a  feeling  of 
stuffing,  buzzing,  and  throbbing  in  the  ear.  The  fever  is  at  times 
considerable — much  more  so  than  would  be  expected  from  so 
slight  a  cause,  and  characterized,  not  so  much  by  alteration  in  the 
circulation,  as  by  evening  paroxysms,  heat  of  skin,  restlessness, 
and  great  anxiety  of  countenance.  From  the  structures  in  which 
they  are  placed,  these  abscesses  are  generally  a  long  time  coming 
to  the  surface,  and  they  almost  invariably  point  internally,  or  to- 
ward the  centre  of  the  external  orifice.  The  contents  of  each  ab- 
scess— which  is  the  analogue  to  a  stye  upon  the  eyelid,  but,  owing 
to  the  structure  in  which  it  is  placed,  it  is  far  more  painful — con- 
sists of  thick  yellow  pus  and  a  hard  core  of  dead  cellular  membrane ; 


the  former  is  sometimes  only  s  drop,  at  other  times  it  is  as  modi 
as  a  drachm. 

The  local  treatment,  most  efficacious  for  preYentiDg  suppora- 
tion  in  these  parts  when  inflammation  has  been  set  np,  is  the  appli- 
cation of  the  solid  nitrate  of  silver  so  as  to  blacken  the  skin.  Ab 
soon  as  we  believe  matter  has  formed,  and  come  some  way  to  the 
surface,  but  not  till  then,  we  should  make  an  incision  with  a  veiy 
small  double-edged  knife.  At  the  same  time  fomentations  and 
poultices,  and  holding  the  ear  over  the  steam  of  hot  water,  will 
afford  relief  both  before  and  after  the  matter  has  been  evacuated. 

Few  diseases  of  the  ear  require  more  careful  constitutional 
treatment  than  this.  After  attention  to  the  state  of  the  digestive 
organs  in  the  usual  fashion,  the  use  of  bark,  with  either  the  li- 
quor potasss  or  Brandishes  alkaline  liquor,  will  assist  to  prevents 
recurrence  of  these  abscesses.  While  the  abscesses  in  the  exter- 
nal meatus  are  appearing  in  the  manner  described  above,  there  is 
generally  some  subacute  inflammation  of  the  lining  of  the  whole 
canal,  attended  with  a  whitish  discharge,  and  in  some  cases  the 
membrana  tympani  is  itself  inflamed,  so  that  we  should,  as  soon 
as  the  parts  will  permit,  examine  the  condition  of  that  structure. 
If  inflamed,  leeches  are  indicated ;  but  unless  applied  in  the  very 
early  stage  of  circumscribed  inflammation,  they  seldom  prevent 
the  formation  of  matter. 

Diffused  inflammation  of  the  external  meahu  is  a  matter  of 
much  more  serious  consequence  than  either  the  profession  or  the 
public  are  aware ;  for,  frequently  as  it  occurs,  and  lightiy  as  it  is 
treated,  it  generally  ends  in  the  establishment  of  a  disgusting  dis- 
ease— otorrhoea,  which  always  impairs  the  hearing,  oftentimes 
leads  to  total  deafness,  and,  in  some  cases,  ends  in  death.  Yet 
how  frequently  do  we  hear  practitioners  speak  of  the  patient  hav* 
ing  ''  only  a  slight  discharge  from  the  ear.**  At  times  the  symp- 
toms of  inflammation  of  the  lining  of  the  meatus  are  so  slight,  and 
produce  such  little  uneasiness,  that  the  patient  first  becomes  con- 
scious of  his  disease  by  feeling  something  wet  in  his  ear,  when 
upon  applying  the  finger,  or  a  towel,  he  discovers  that  a  discharge 
of  thin,  whitish,  muco- purulent  matter^has  been  established;  or 
in  infants  and  young  children,  about  the  period  of  dentition,  the 


nurses  and  attendants  observe  the  flow  of  matter  as  the  earliest 
symptom  of  the  disease.  This  is  the  subacute  or  catarrhal  inflam- 
maiion  of  the  dermis,  and  the  external  layer  of  the  membrana 
tympani,  which  is  always  attended  with  otorrhoea,  and  which  fre- 
quently remains  in  a  chronic  condition  for  years.  The  state  of 
the  external  aperture  on  the  first  onset  of  the  disease,  and  before 
it  has  become  thickened  or  excoriated  by  the  discharge,  is  nor- 
mal ;  but  within,  the  cuticle  is  white,  pulpy,  and  detached,  and 
the  skin  beneath  it  is  usually  of  a  pinkish  colour.  This  is  a  dis- 
ease of  infancy  and  youth,  and  is  one  of  the  most  decidedly  stru- 
mous affections  with  which  I  am  acquainted,  not  only  from  its 
appearing  in  persons  of  well-marked  scrofulous  character,  but  from 
its  being  so  frequently  a  concomitant  of  other  scrofulous  affec- 
tions, particularly  of  the  lungs.  Out  of  2385  cases  recorded  in 
the  Table  at  page  102,  there  were  516  of  chronic  otorrhoea,  the 
males  predominating  somewhat  over  the  females. 

Aettte  inflammation  diffused  over  the  external  meatus  may  be 
either  idiopathic,  as  fro£  cold ;  traumatic,  from  a  foreign  body 
or  any  irritating  substance  introduced  into  the  meatus ;  or  spe- 
cific, as  when  it  occurs  in  the  course  of  some  of  the  exanthema- 
tous  fevers,  is  produced  by  infection  with  gonorrhoeal  matter,  or 
is  attended  by  such  other  symptoms  in  persons  where  there  is  a 
decided  diathesis  that  it  may  be  termed  rheumatic.  This  latter 
need  not  end  in  suppuration  or  otorrho&a;  the  previously  specified 
forms  generally  do.  To  these  different  forms  of  inflammation, 
classified  in  the  nosological  chart  at  page  147, 1  have  added  that 
of  periosteal,  to  define  that  particular  kind  of  inflammation  usu- 
ally accompanied  with  otorrhoea,  which,  sooner  or  later,  spreads 
to  the  periosteum  and  the  bone  of  the  auditory  canal,  and  from 
thence  to  neighbouring  structures,  often  producing  fatal  conse- 
quences. When  once  a  discharge  is  established,  no  matter  from 
what  cause,  but  more  particularly  when  it  results  from  subacute 
or  chronic  inflammation  of  the  lining  of  the  meatus,  and  the  ex- 
ternal surface  of  the  membrana  tympani, — which,  in  such  cases, 
generally  becomes  muco-secreting, — we  have  then  a  special  dis- 
ease to  treat,  denominated  external  otorrhooa,  which  shall  be  con- 
sidered in  the  chapter  upon  that  subject. 


194  iMWiAMMk'AomB  or  thb  mxrmaaAL  mbatub. 

Acute  inflammation  of  the  meatus  can  weueelj  exist,  or  pro* 
cecd  to  any  extent,  without  engaging  the  external  layer  of  the 
membrana  tympani.  The  inflammatory  action  may  be  limited  to 
these  two  situations ;  where  known,  the  disease  is  characterised  by 
Tiolent  pain  and  fevers  it  seldom  is  so,  but  usually  engages  the 
mucous  membrane  of  the  cavity  of  the  tympanum,  as  is  proved 
by  the  frequent  rupture  of  the  membranous  diaphragm  between 
these  two  portions  of  the  auditory  apparatus.  Such  is  generally 
the  case  in  those  inflammations  attending  eruptive  fevers,  scarla- 
tina in  particular,  where  the  mucous  membrane  of  the  throat  and 
ear,  as  well  as  the  glandular  structures  of  the  neck,  are,  in  the  s^ 
vere  instances  of  that  affection,  so  frequently  engaged ;  but  ia 
these  latter  I  am  inclined  to  think  the  disease  spreads  to  the  audi- 
tory organ  more  frequently  from  the  throat  than  the  skin. 

Acute  inflammation  of  the  meatus  is  characterised  at  first  by 
dryness,  itching,  and  heat  of  the  part,  gradually  increasiDg  to  a 
dull  aching,  and  eventually  to  an  acute  lacerating  pain,  generally 
increased  at  night,  and  in  some  instanc^  amounting  to  insufiera* 
ble  agony,  with  loss  of  rest,  fever,  and  even  delirium.  The  lining 
of  the  meatus  is  swollen:  at  first  dry  and  pinkish,  then  white  and 
muculent ;  and  at  that  stage  I  have  on  several  occasions  seen  the 
whole  of  the  bony  portion  of  the  tube  and  the  external  surftcsof 
the  membrana  tympani  coated  with  a  layer  of  plastic  lymph.  In 
a  short  time  a  scro-mucous  or  muco- purulent  discharge  is  estab- 
lished, or  yellow  pus  pours  from  the  meatus,  and  relief  is  thai 
generally  experienced.  Attendant  upon  these  feelings  and  ap* 
pearances  there  is,  particularly  in  rheumatic  cases,  a  sensation  of 
soreness  over  that  side  of  the  heud,  and  all  the  symptoms  are  in* 
creased  by  sneezing,  coughing,  chewing,  or  moving  the  jaw  in 
any  manner.  As,  however,  the  hemicranial  pain,  and  many  td 
the  other  symptoms  detailed,  are  common  to  inflammations  of  the 
cavitas  tympani  and  general  otitis,  it  is  often  difficult  to  distin- 
guish  external  from  internal  inflammation  of  the  ear.  The  fol* 
lowing  case  of  acute  inflammation  of  the  external  auditory  tube 
and  membrana  tympani  (No.  16  in  the  Registry),  is  characteristic 
of  this  afiection : — 

T.  S.,  aged  46,  a  shopman,  complains  of  deafness  in  his  left 


ear,  of  a  fortnight's  duration,  accompanied  by  a  buzzing  noise  and 
throbbing.  The  disease  commenced  late  in  the  evening,  with  se- 
vere pain,  which  continued  all  night,  and  which,  although  miti- 
gated, has  never  entirely  ceased  since,  but  is  always  most  distress- 
ing at  night.  Upon  the  fifth  or  sixth  day  he  perceived  a  *^  slight 
moisture''  in  his  ear,  but  was  not  conscious  of  any  sudden  burst,  or 
a  feeling  as  if  something  had  given  way  within.  The  external 
meatus  and  auditory  tube,  as  well  as  the  surface  of  the  membrana 
tympani,  are  coated  over  with  a  tenacious  muco-cerumenous  dis- 
charge, upon  the  removal  of  which  the  entire  surface  brought  into 
view  appears  of  a  florid  red,  becoming  pinkish  and  spotted  with 
ivhite  on  the  face  of  the  membrana  tympani.  Flakes  of  cuticle 
adhere  to  the  walls  of  the  canal.  The  spots  on  the  membrana 
tympani  appear  to  be  patches  of  lymph  effused  on  its  surface ; 
they  are  more  of  a  yellow  colour  than  the  specks  of  cuticle  on  the 
tube.  The  membrana  tympani  is  still  imperforate.  We  occa- 
aionally  find  the  whole  surface  of  the  tympanal  membrane  covered 
over  with  a  sheet  of  lymph  like  that  which  lines  the  trachea  in 
cases  of  croup.  He  cannot  hear  the  watch  even  on  touching. 
On  the  right  side  the  parts  are  healthy,  and  the  hearing  good. 
The  treatment  recommended  to  the  patient  has  only  aggravated 
his  disease, — brandy  and  oil,  laudanum,  hot  salt,  and  various  sti- 
mulating applications,  having  been  poured  into  the  meatus. 

This  is  a  case  too  manifest  to  be  mistaken ;  and,  from  the  to- 
tal loss  of  hearing  upon  the  left  side,  it  is  probable  that  the  inflam- 
matory action  has  extended  to  all  the  layers  of  the  membrana 
tympani,  and  has  also  passed  into  the  cavity  of  the  middle  ear. 
Had  it  commenced  in  the  latter,  the  pain  and  attendant  fever 
would  have  been  greater,  and,  on  suppuration  taking  place,  the 
membrana  tympani  would  probably  have  been  ruptured  to  allow 
the  exit  of  the  matter,  and  the  case  would  now  be  one  of  internal 
otorrhosa,  with  perforation.  Cases  of  this  nature  are  very  common 
during  the  winter  months,  or  when  cold  east  winds  prevail  in 
March  and  April ;  and  are  frequently  induced  by  travelling  upon 
the  top  of  a  coach,  sitting  opposite  an  open  door  or  a  broken 
window,  or  being  exposed  to  a  draught  of  cold  air  in  any  situ- 
ation.    I  am  frequently  consulted  by  Roman  Catholic  clergymen 



during  the  season  of  Lent,  for  inflammation  of  the  ear  ftcquiTed 
while  sitting  in  the  confessional-box,  often  for  hours  together,  in 
cold,  exposed  places  of  worship,  with  the  ear  applied  to  a  small 
aperture  through  which  the  wind  is  playing.  In  the  foregoing 
case,  local  depletion,  continued  counter-irritation,  and  altermtiTe 
doses  of  mercury,  restored  the  parts  to  a  healthy  condition,  and  the 
hearing  returned.  In  some  cases  of  inflammation  of  the  auditory 
canal,  the  auricle  is  hot  and  swollen ;  but  in  no  instance  does  it 
erer  assume  the  osdematous  character  which  the  eyelids  present 
in  severe  ophthalmia. 

The  treatment  of  acute  inflammation  of  the  external  auditory 
conduit  should  be  strictly  antiphlogistic.  Local  depletion,  by 
means  of  leeches  applied  round  the  meatus,  or  the  neighbourhood 
thereof,  after  the  manner  described  at  page  85,  is  indicated  in 
almost  every  case.  Purgation  is  always  attended  with  advantagOt 
and  the  patient  experiences  great  comfort  from  the  application  of 
heat  and  moisture.  Mercury  is  seldom  indicated  unless  when  the 
membrana  tympani  is  deeply  implicated.  Counter-irritation  should 
follow,  but  unless  in  mild  cases,  never  precede,  depletion.  Astrin- 
gent lotions  should  be  used  with  caution  until  the  disease  is  in  a 
subacute  or  chronic  form,  when  it  becomes  a  case  of  ordinary 
otorrhoea.  I  have  seen  small  granulations  sprout  from  the  lower 
portions  of  the  canal  within  eight  or  ten  days  after  the  first  acoes- 
sion  of  inflammation  of  this  portion  of  the  ear,  but  generally 
speaking  they  occur  at  a  much  later  date,  and  are  more  usually 
attendant  on  disease  of  the  deeper-seated  structures.  Superficial 
ulcers  form  both  on  the  dermal  lining  of  the  meatus  and  the  ex- 
ternal layer  of  the  membrana  tympani. 

Continental  authors  have  enumerated  gonorrhaa  among  the 
causes  of  inflammation  and  otorrhoea  from  the  external  meatus, 
and  upon  the  authority  of  writers  I  have  inserted  this  disease  in 
the  nosological  chart,  although  I  myself  have  never  met  a  case 
that  could  be  fairly  traced  to  it,  either  by  metastasis  or  the  direct 
application  of  specific  virus  to  the  part.  Mr.  Harvey,  of  London, 
wrote  an  essay  on  venereal  aflections  of  the  ear,  in  the  London 
Journal  of  Medicine  for  February,  1852,  in  which  he  alludes  to 
the  analogy  between  ophthalmia  neonatorum  and  in&ntile  otor^ 


rhoea  produced  by  the  contagion  of  specific  matter.  I  must,  how* 
ever,  for  my  own  part,  confess,  that  I  am  unacquainted  with  that 
^  obstinate  form  of  infantile  otorrhcda  which  occurs  shortly  after 
birth,  not  unfrequently  destroying  the  organ,  and  producing  as  a 
consequence  both  deafness  and  dumbness  for  life,"  alluded  to  by 
the  author*  In  order  to  trace  it  to  infection  by  direct  contact,  the 
disease  ought  to  appear  within  the  first  fourteen  days  at  the  latest 
after  birth,  whereas  every  accoucheur,  or  physician  familiar  with 
the  diseases  of  children,  is  well  aware  that  the  muculent  discharge 
of  infants  does  not  in  general  appear  until  after  the  second  month, 
and  still  more  frequently  not  until  dentition  commences*  The 
case  related  by  Mr.  Harvey  does  not  support  his  hypothesis,  or 
bear  scrutiny.  A  man  labouring  under  gonorrhoea  and  hernia  hu* 
moralis  is  '*  seized  with  intense  itching  in  his  ear,  accompanied 
with  paroxysms  of  pain ;  and  shortly  afterwards  there  issued  a  pro- 
mise yellowish  discharge."  To  account  for  the  disease  the  author 
says,  **  Let  us  suppose  the  man's  finger  to  have  been  soiled  with 
the  urethral  discharge,  and  that  on  an  occasion  of  an  intense  de« 
gree  of  itching  in  the  external  ear  (the  very  first  symptom  com- 
plained of  by  the  patient),  he  had  thoughtlessly  and  with  some 
violence  thrust  his  finger  into  the  meatus,  possibly  abrading  the 
membrane  with  his  nail."  He  also  quotes  Lincke's  description  at 
length,  but  it  does  not  contain  any  one  diagnostic  wherewith  to 
distinguish  this  form  of  inflammation  firom  that  arising  from  any 
other  cause,  and  we  require  experiments  to  establish  the  fact  that 
the  external  meatus  is  susceptible  of  gonorrhosal  infection. 

Whatever  may  be  the  cause  of  the  inflammation  in  the  lining 
of  the  meatus,  the  diseased  action,  once  set  up,  may  spread  sooner 
or  later  to  the  periosteum  and  the  bone,  causing  necrosis,  exfoli- 
ation, cerebral  disease,  and  death.  It  is,  therefore,  a  disease  at  all 
times  demanding  the  serious  attention  of  the  surgeon,  and  requir- 
ing prompt  and  energetic  measures  for  its  arrest.  Mr.  Toynbee, 
in  an  elaborate  and  ingenious  article  in  the  Medico-Chirurgical 
Transactions,  vol.  xxiv.,  has  endeavoured  to  show  that  disease  of 
particular  portions  of  the  ear  are  propagated  from  or  give  rise  to 
disease  in  particular  portions  of  the  brain ;  thus,  when  inflamma- 
tion or  its  results  is  seated  in  the  external  meatus  or  mastoid  cells» 


the  cerebral  affection  will  be  found  in  the  lateral  rinns  and  cere^ 
bellum ;  from  the  tympanic  cavity,  disease  is  propagated  to  the 
cerebrum ;  and  from  the  labyrinth  to  the  medulla  oblongata  and 
base  of  the  brain.  The  author  has  collected  and  arranged  in  a 
tabular  form  a  number  of  cases  of  death  produced  by  extension 
of  disease  from  the  ear  to  the  brain,  or  its  membranes,  in  which 
post-mortem  examinations  were  made ;  but  although  these  cases, 
and  many  others  well  known  to  surgeons,  and  scTcral  additional 
ones  recorded  by  members  of  the  profession  in  this  ci^,  to  which 
I  shall  have  occasion  to  refer  in  another  place, — all  prove  the  iatal 
nature  of  many  of  these  aural  affections, — they  certainly  do  Bd 
establish  the  theory  *<  that  each  of  the  cavities  of  the  ear  haa  its 
particular  division  of  the  encephalon  to  which  it  communicates 


Diseases  of  the  skin,  particularly  herpetic  and  eezematoue  enep^ 
tions,  extend  from  the  auricle  into  the  meatus;  or  thej  may  be 
seated  in  the  latter  alone.  In  either  case  the  treatment  is  similar. 
If  allowed  to  proceed  unchecked,  they  produce  thickening  of  the 
lining  of  the  passage,  lessening  its  caliber,  and  in  time  steal  over 
the  external  layer  of  the  membrana  tympani.  As  the  result  of 
chronic  inflammation,  the  lining  of  the  meatus  becomes  thickenedf 
and  may  sometimes  be  peeled  off  like  the  detached  cuticle  of  a 
blister  or  bum  upon  any  of  the  exposed  surfaces  of  the  body. 
There  is  a  thick  pasty  matter,  not  unlike  the  softened  cuticle  which 
may  be  scraped  from  the  soles  of  the  feet,  sometimes  coating  over 
the  passage:  and  occasionally  the  whole  thimble-like  cuticular 
lining  of  the  meatus  comes  out  eti  fnasse.  In  all  these  cutaneous 
affections,  in  addition  to  the  treatment  already  referred  to  when 
they  are  seated  in  the  auricle,  great  benefit  will  be  derived  fiom 
the  application  of  a  solution  of  nitrate  of  silver, — ten  grains  to 
the  ounce ;  and  subsequently,  when  the  lining  has  become  more 
healthy,  the  use  of  the  citrine  ointment,  referred  to  at  page  171. 
Bell,  in  his  work  on  Lues,  speaks  of  deafness  produced  by  a  **9CTuffj 
eruption,""  and  sometimes  ulceration  of  the  external  auditory  pas- 
sage, occurring  as  a  consequence  of  that  disease ;  but  his  descrip- 


don  is  not  sufficiently  accurate  to  be  depended  upon,  and  has  not 
been  confirmed  by  subsequent  observers.  No  doubt,  cutaneous 
syphilitic  disease  will  extend  by  ordinary  continuity  of  surface 
into  the  meatus,  but  as  a  special  form  I  am  unacquainted  with  it. 

I  have  seen  cases  of  intolerable  itching  of  the  mealus^  with  a 
dry  branny  state  of  the  cuticle,  lasting  for  months,  and  giving  rise 
to  heat  and  redness  of  the  auricle.  Paroxysms  of  the  disease  come 
on  at  stated  periods,  generally  in  the  evening.  Cases  of  this  na- 
ture, and  all  other  diseases  of  the  meatus,  attended  by  extreme 
dryness  and  an  unhealthy  state  of  the  cerumenous  secretion,  will 
be  benefited  by  the  application  of  glycerine,  and  some  by  the  solu- 
tion of  gutta  percha  in  chloroform. 

The  amount  of  hair  growing  round  the  meatus  and  attached 
to  the  posterior  surface  of  the  tragus  is  very  various.  Sometimes, 
particularly  in  persons  from  fifty  to  sixty  years  of  age,  the  vibriescB 
fall  out,  and  resting  either  on  the  meatus  or  membrana  tympani, 
cause  intense  annoyance,  and  at  times  produce  increased  redness 
of  the  lining  of  the  passage.  Syringing  affords  but  little  relief, 
for  the  wet  hairs  only  adhere  to  the  parts  more  intimately.  The 
meatus  must  be  carefully  inspected  with  the  speculum  under  strong 
sunlight,  and  each  hair  gently  removed  with  a  long  fine  forceps. 
It  requires  some  delicacy  of  manipulation  to  lift  a  hair  from  off 
the  membrana  tympani  without  giving  the  patient  pain;  but  it  is 
the  only  effectual  remedy. 

Ulceration  of  the  meatus  is  of  itself  a  rare  disease ;  but  it  is  a 
frequent  concomitant  of  other  affections,  such  as  otorrhoBa,  or  the 
irritation  of  substances  introduced  either  by  accident  or  for  cura- 
tive purposes.  It  often  attends  chronic  erysipelas,  and- also  condy« 
lomatous  growths  at  the  orifice  of  the  canal.  Extreme  cleanliness, 
mild  astringent  washes,  the  application  of  nitrate  of  silver,  toge- 
ther with  the  constitutional  treatment  recommended  at  page  170, 
will  generally  cure  cases  of  this  description. 



Variations  from  the  normal  caliber  of  the  external  meatus  may 
arise  from  a  number  of  causes, — viz.,  collapse  of  the  flexible  por- 


tion  of  its  walk,  of  which  an  example  is  gi^en  below;  or  the  ob- 
▼erse  state,  in  which  the  external  aperture  is  pretematurally  wide 
— a  common  consequence  of  long-continued  otorrhoea;  strictoiet 
either  congenital  or  acquired,  in  its  middle  part,  and  alao  morbid 
growths,  such  as  polypous,  bony,  or  other  tumours. 

No.  20  in  the  Registry  is  a  case  of  domire  of  the  extenud  mso- 
tu8;  in  T.  S.,  a  female,  aged  54,  who  says  she  became  deaf  gra* 
dually  during  the  last  three  or  four  years.  Has  tinnitus  anriam; 
but  no  pain  or  soreness  in  the  ear.  There  is  little  to  be  learned 
from  the  history  of  this  case ;  but  a  glance  at  the  ezlemal  ear 
affords  a  tolerably  good  idea  of  the  cause.  Upon  looking  at  the 
meatus  we  perceive  that  it  has  lost  its  usual  OToid  shape,  and 
has  become  a  mere  elongated  slit  or  fissure  marked  by  a  dark 
line  where  the  incunrated  edges  are  in  contact  Upon  drawing 
forward  the  tragus,  we  rather  increase  the  defect,  but  by  grasp- 
ing the  auricle  immediately  above  the  anti-tragus,  and  drawing 
it  outwards  and  a  little  forward,  we  can  to  a  certain  extent  restore 
to  its  natural  size  and  posidon  the  external  auditory  aperture. 
The  hollow  formed  between  the  tragus  and  the  external  meatus 
is  much  larger  and  shallower  than  natural ;  and  on  pressing  with 
the  finger  in  front  of  the  tragus  and  beneath  the  sygonu^  where 
the  skin  is  rather  corrugated,  we  are  unable  to  push  the  tragus 
backwards  into  the  concha  so  as  to  cover  the  meatus  extemus,  to 
which  in  normal  cases  it  ought  to  act  as  a  sort  of  operculum* 
Upon  examination  with  the  speculum,  we  find  the  flexible  walls 
of  the  auditory  tube  compressed,  the  lining  of  the  passage  white, 
and  its  cuticular  investiture  thickened  as  if  by  maceration,  and 
detached  in  patches,  while  a  slight,  whitish,  curdy  discharge  col- 
lects round  the  edge  of  the  tubular  speculum.  The  tympanal 
membrane  is  white,  and  apparently  thickened.  There  is  no  evi- 
dence of  cerumenous  secretion  in  any  portion  of  the  passage. 

Upon  enlarging  the  external  meatus,  either  by  the  means  first 
pointed  out,  or  by  the  introduction  of  the  speculum,  the  hearing 
is  increased.  She  can  now  perceive  the  ticking  of  the  watch  at 
six  inches;  previously  she  only  heard  it  when  pressed  against  the 

Closure  of  the  external  meatus  may  arise  from  a  variety  of 


causes,  of  which  I  possess  examples  in  an  extensive  series  of 
drawings.  In  the  instance  detailed,  it  does  not  seem  to  be  the 
result  of  any  inflammatory  process,  but  appears  to  have  been 
caused  by  some  force  gradually  exerted  upon  the  tragus,  drawing 
its  point  forward  toward  the  cheek,  and  pressing  its  base  back- 
wards,— ^possibly  permanent  spasm  of  the  tragicus  muscle.  It  is 
a  very  slow  and  gradual  process,  and  is,  therefore,  seldom  attended 
to  by  the  patient  until  complete  closure  of  the  meatus  ensues. 
The  deficiency  of  cerumen,  the  thickened  cuticle,  and  the  slight 
discharge  observed  in  the  passage,  are  the  result,  not  of  the  origi- 
nal disease,  but  the  subsequent  closure  and  pressure  of  the  sides 
against  each  other.  It  is  a  disease  of  middle  or  advanced  age; 
and  although  it  attacks  one  ear  first,  it  generally  appears  in  that 
on  the  opposite  side.  It  is  most  difiicult  to  manage.  I  have  had 
thoughts  of  making  an  incision  in  front  of  the  tragus,  so  as  com- 
pletely to  divide  any  muscular  fibres  which  might  have  produced 
the  deformity ;  but  I  fear  that  plan  would  not  be  attended  with 
much  success,  for  I  have,  from  long  experience,  remarked  that 
when  once  any  of  the  free  cartilages,  as  the  eyelids,  nose,  or  au- 
ricle, become  viciously  bent  or  distorted  from  their  natural  posi- 
tion or  curvature,  that  it  is  almost  impossible  to  restore  them  by 
any  effort  of  art.  I  have  used  tents  made  of  compressed  sponge 
for  the  purpose  of  gradual  dilatation,  but  I  cannot  say  that  I  have 
effected  much  thereby ;  they  should,  however,  be  given  a  fair  trial 
in  every  case.  The  canal  ought  to  be  cleansed  firom  those  impu- 
rities which  collect  therein,  and  the  parts  washed  over  with  a 
strong  solution  of  nitrate  of  silver,  and  a  fresh  tent  should  be  in- 
troduced every  night,  and  removed  in  the  morning.  With  intel- 
ligent persons,  in  the  upper  ranks  of  life,  this  plan  of  treatment, 
if  proceeded  with  for  a  sufficiently  long  time,  will  be  attended 
with  benefit;  but  with  careless,  stupid  people,  among  the  lower 
orders,  who  pay  little  attention  to  cleanliness,  it  has  but  a  slight 
chance  of  success.  Defective  hearing  arising  from  this  appa- 
rently mechanical  cause  is  one  of  the  few  diseases  that  may  be 
relieved  by  the  introduction  of  a  small  metallic  tube  shaped  like 
a  wine-funnel.  We  see  those  constantly  advertised  as  a  means 
of  relieving  every  description  of  deafness.     I  need  not  say  that, 


from  the  rarity  of  the  peculiar  diBoase  to  which  thej  are  i^plica- 
ble,  how  very  few  caaes  they  can  afford  relief  to.  A£»  howevery 
they  are  silver-gilt,  are  sold  in  very  neat  morocco  caaea,  and  cost 
a  guinea,  they  serve  the  purposes  for  which  they  are  advertised: 
they  do  not  cure ;  they  only  sell.  Baron  Larrey,  the  inventor  of 
these  tubes,  supposed  that  the  disease  which  they  are  intended 
to  remedy  was  caused  by  loss  of  the  molar  teeth  of  one  or  other 
maxilla  in  early  life,  when  he  says  there  results  a  **  gradual  dis* 
placement,  upwards  and  backwards,  of  the  condyles  of  the  lower 
jaw-bone,  which  sink  into  the  glenoid  cavities  of  the  tempwal 
bones  so  as  to  become  lodged  at  the  bottom  of  the  articular  cavi- 
ties, beyond  the  Glasserian  fissure,  and  before  the  meatus  extemos^ 
the  parietes  of  which  will  then  be  depressed  in  the  same  direction ; 
the  auditory  passage  i^gradually  obliterated,  or  undergoes  such 
an  alteration  that  the  rays  of  sound  can  no  longer  reach  the  tym- 
panum, from  whence  results  deafness."  I  have  seen  cases  of  this 
disease,  however,  in  which  the  molars  had  not  been  lost. 

Several  years  ago  I  had  under  my  care  a  case  of  this  descrip- 
tion, in  a  very  intelligent  old  gentleman,  and  having  made  an  ac- 
curate wax  cast  of  the  concha  and  meatus,  while  the  latter  was 
drawn  open,  as  already  described,  Mr.  Grimshaw  made  for  him 
a  silver  tube,  which,  fitting  accurately  to  the  parts,  gave  no  in- 
convenience, was  not  remarkable,  and  very  much  improved  the 
hearing.  Pads  have  been  constructed  to  fit  behind  the  ear,  and 
press  the  auricle  forwards,  but  they  do  not  afford  the  desired  relief. 
Persons  who  are  aware  of  this  cause  of  their  deafness  do  not,  when 
conversing,  place  the  half-closed  hand  behind  the  auricle,  in  order 
to  collect  sound,  but  very  soon  learn  how  to  enlarge  the  meatus^ 
by  drawing  the  auricle  outwards  and  a  little  backwards. 

In  ordinary  cases  of  otorrhoea,  particularly  where  the  discharge 
is  profuse,  the  meatus  is  often  rather  larger  than  natural,  and  the 
excoriations,  which  sometimes  occur  where  the  matter  is  of  an 
ichorous  character,  being  always  more  or  less  moist,  and  not  form- 
ing crusts  and  scabs,  do  not  produce  any  contraction  of  the  exter- 
nal aperture ;  but  other  cases  present  where  the  meatus  is  closed 
by  morbid  growths,  of  which  the  following  instance  is  an  ex- 


Condyloma  of  the  external  meatus  is  a  rare  form  of  disease. 
M.  D.  L.  (No.  21  in  Registry ),  a  female,  aged  25,  saffers  from 
deafness,  tinnitus,  occasional  pain,  foetid  and  sometimes  bloody 
discharge  from  left  ear,  for  eight  months ;  is  otherwise  healthy ; 
attributes  her  affection  to  cold.  The  external  meatus  is  completely 
closed  by  several  condylomata  which  grow  around  its  margin,  but 
particularly  from  its  lower  edge.  They  are  rather  sensiuve  to 
tbe  touch,  lobulated  on  their  surface,  project  a  considerable  dis- 
tance beyond  the  margin  of  the  aperture,  and  are  a  little  more 
florid  in  colour  than  the  natural  skin.  When  the  tragus  is  pressed 
backwards  with  the  6nger,  a  muco-purulent  offensive  discharge 
exudes  between  these  growths.  It  is  not  possible  to  insert  even  a 
small-sized  speculum  into  the  meatus  without  causing  great  pain 
and  irritation.  She  can  only  hear  the  watch  on  touching.  The 
right  ear  is  normal.  The  excrescences  were  touched  with  solid 
nitrate  of  silver,  after  which  a  poultice  was  applied.  The  subse- 
quent treatment  consisted  in  washing  over  the  morbid  growths 
with  a  strong  solution  of  nitrate  of  silver  every  second  or  third 
day,  and,  in  the  intermediate  time,  keeping  a  dossil  of  fine  lint, 
wet  with  diluted  liquor  plumbi,  applied  to  the  concha ;  besides 
the  internal  administration  of  Plummer*s  pill  and  sarsaparilla.  By 
persisting  in  this  treatment  for  upwards  of  two  months,  the  condy- 
lomata disappeared,  leaving  the  meatus  natural,  when  the  mem- 
brana  tympani  was  found  unimpaired,  and  the  hearing  was  restored. 

The  following  case,  No.  24  in  the  Registry,  presented  an  un- 
common form  of  tumour  in  the  meatus: — 

M.  N.,  a  female,  aged  47,  has  been  deaf  of  the  right  ear  for 
many  years,  and  is  much  annoyed  by  itching  and  a  stuffed  feeling 
in  the  meatus.  A  tumour,  in  shape,  size,  and  colour  resembling 
a  half-ripe  mulberry,  occupies  the  anterior  and  lower  edge  of  the 
meatus,  and  extends  some  way  into  the  auditory  tube,  which  it 
almost  completely  blocks  up.  It  is  not  unlike  that  disease  known 
here  as  *'  button  scurvy,"  and  to  which  the  late  Dr.  Wallace  of  this 
city  gave  the  name  o(  morula.  It  is  attached  by  its  broad  base 
throughout  its  whole  extent,  and  has  neither  enlarged  nor  ex- 
tended for  the  last  five  years,  during  which  time  I  have  been  in  the 
habit  of  examining  it  occasionally.     The  patient  never  had  otor- 

204         8Z0fTO8I8  or  XHB  SZTBBVAL  MBATUl. 

rhoea;  and  there  is  no  discharge  now  present,  but  at  times  the 
tumour  becomes  painful  and  irritable^  and  then  its  colour  deep^is 
from  a  florid  red  to  a  purple.  It  is  of  a  firm  consistence,  corru- 
gated on  its  surface,  and  has  an  unyielding  feel,  quite  unlike  a 
nasvus,  for  which  at  first  sight  it  might  be  mistaken.  I  have  not 
meddled  with  this  tumour,  as  I  once  saw,  and  have  described  at 
page  206,  an  affection  somewhat  similar  in  external  appearanoei 
in  a  lady  about  this  woman's  time  of  life,  end  in  malignant  disease, 
apparently  hastened  by  treatment. 

We  meet  with  various  other  growths  in  the  external  meatus 
and  auditory  tube,  independent  of  polypus  or  other  morbid  pro- 
ducts,  resulting  from  inflammation  or  its  consequences.  One  of 
the  most  frequent  of  these  is  esodatUt  of  which  I  have  seen  very 
many  examples.  The  projection  generally  grows  from  the  poste- 
rior edge  of  the  osseous  portion  of  the  tube,  and  slowly,  but  gia* 
dually,  projects  forwards,  so  as  to  leave  but  a  slight  crescent-shaped 
fissure  between  it  and  the  anterior  wall  of  the  meatus.  The  inte- 
guments covering  such  growths  are  generally  very  smooth,  white, 
and  polished.  I  have  seldom  seen  this  disease  affect  both  ears,  but 
I  have  often  remarked  it  in  connexion  with  inflammatory  aflbe- 
tions  both  of  the  external  tube  and  the  membrana  tympani.  An* 
tenrieth  has  given  an  account  of  one  of  these  growths ;  and  in  1849 
Mr.  Toynbee  communicated  a  valuable  paper  on  the  subject  to  the 
Provincial  Medical  and  Surgical  Journal,  giving  an  account  of 
twelve  cases.  That  paper  is  illustrated  with  woodcuts  represent- 
ing views  and  sections  of  a  portion  of  the  temporal  bone  in  a  dry 
state,  exhibiting  in  particular  the  mastoid  process,  and  a  section 
of  the  bony  meatus,  in  order  to  show  the  position  of  the  encroach- 
ments made  by  these  morbid  growths.  I  do  not  think  it  at  all  un- 
likely that  the  temporal  bones  of  the  various  persons  alluded  to 
in  Mr.  Toynbee*8  paper  may,  after  death,  present  the  appearances 
which  he  has  delineated :  and  the  diagrams  showing  the  form  of  the 
meatus,  and  the  amount  of  bony  growth  therein,  are,  no  doubt,  per^ 
fectly  allowable :  but  I  am  not  so  well  satisfied  with  illustrations  of 
any  kind  except  such  as  are  absolutely  drawn  from  nature.  The 
treatment  recommended  for  these  growths  is  the  appUeation  of 
iodine :  when,  however,  the  disease  has  advanced  to  any  extent,  I 

BX0BT08I8  or  THB  SZTBBVAL  M8ATU8.  205 

haTe  not  much  faith  in  any  remedy ;  but  in  the  early  stage^  when 
the  exostosis  is  probably  the  result  of  chronic  periostitis,  local  de- 
pletion, counter-irritation,  and  mercurials,  will  arrest  its  progress. 
Fortunately,  these  little  bony  nodules,  which  very  much  resemble 
the  excrescences  which  grow  from  the  beech  tree,  are  usually  of 
very  slow  growth.  I  know  one  which  has  not,  apparently,  in- 
creased during  the  last  eight  years.  On  the  contrary,  I  may  men- 
tion having  just  seen  a  case,  in  consultation  with  Dr.  Morgan,  in 
a  gentleman  who  asserts  that  he  heard  quite  well  with  both  ears 
twelve  months  since ;  he  then  began  to  lose  the  hearing  of  the 
right,  which  is  now  quite  gone.  A  few  months  ago  the  left  was 
nmilarly  attacked,  and  he  can  only  hear  with  that  ear  by  insert- 
ing the  finger  for  some  distance  into  the  concha,  and  forcibly 
drawing  the  tragus  downwards.  Being  much  occupied  with  bu- 
siness, he  paid  no  attention  to  his  disease ;  at  least  he  sought  no 
adyice  for  it  until  the  past  week.  Tet  this  is  a  gentleman,  I  am 
told,  of  considerable  professional  acquirements,  and  conducting  an 
extensive  business.  It  seems  almost  incredible  with  what  apathy 
and  indifference  men  reputedly  clever  will  permit  their  hearing  to 
be  lost  without  making  any  effort  for  its  restoration.  But,  although 
they  have  allowed  the  day  of  grace  to  pass  by,  many  of  them  are 
not  slow  in  enlightening  society  upon  the  subject  of  the  impossi- 
sibili^  of  curing  deafness,  or  their  complete  want  of  faith  in  me- 
dicine. In  the  case  of  Mr.  B.,  just  alluded  to,  the  external  meatus 
on  the  right  side  is  completely  closed  by  a  hard,  smooth  exostosis 
growing  from  its  posterior  bony  wall,  and  filUng  up  the  canal  so 
perfectly  that  no  vestige  of  it  can  be  seen  except  a  crescentic  line 
where  the  new  growth  meets  the  anterior  wall.  He  cannot  hear 
the  watch  even  when  pressed  against  the  auricle.  *  The  progress 
of  the  disease  has  not  been  attended  with  pain,  and  the  gentleman 
is  in  perfect  bodily  health.  Upon  the  left  side  he  can  hear  the 
watch  when  pressed  against  the  auricle,  there  being,  fortunately 
for  the  patient,  two  exostoses,  which,  meeting  by  their  convex  sur- 
fiu^es,  have  prevented  complete  closure  of  the  inferior  portion  of 
the  meatus,  and  as  there  are  still  manifestations  of  inflammatory 
action  going  forward  in  the  meatus,  treatment  holds  out  a  hope  of 
improvement.    (See  page  209.) 


Schmalz  has  figured  a  small  exostosis  from  the  work  of  Plater- 
nus,  which  grew  within  the  vestibule;  and  several  instances  have 
been  recorded  of  exostoses  within  the  cavity  of  the  tympanum. 

When  otorrhoea  has  been  long  established,  or  that  caries  has 
taken  flacet  fiUulaua  opentng$  form  between  the  external  meatus 
and  the  mastoid  or  aural  regions.  In  the  former  situation  they  are 
not  at  all  uncommon ;  I  have,  in  two  instances,  seen  sinuses  five 
inches  in  length,  extending  from  the  external  auditory  canal  along 
the  side  of  the  neck,  and  not  long  since  there  was  a  patient  at  the 
Hospital  labouring  under  phthisis  and  otorrhoda,  who  could  pump 
the  matter  out  of  his  ear  by  pressing  upon  an  abscess  situated  over 
the  upper  edge  of  the  scapula. 

Polypi  in  the  external  meatus  are  very  common,  and  gene* 
rally  grow  from  some  part  of  the  bony  portion  of  the  canal.  As 
they  are  always  attended  with  otorrhcsa,  they  shall  be  considered 
in  the  chapter  devoted  to  that  subject.  The  consideration  of  m- 
ries  also  belongs  to  the  chapter  upon  otorrlioea. 


Malignant  diseases  in  the  external  meatus  are  very  rare,  al- 
though they  may  engage  that  part  in  some  stage  of  their  progress. 
Of  lupoid  ulcerations,  and  cutaneous  cancer,  I  have  already  spoken 
at  page  172.  Osteosarcoma  of  the  lower  jaw  or  the  malar  bone 
sometimes  encroaches  upon  the  meatus,  as  may  be  seen  in  the  mor- 
bid specimens  in  our  museums.  The  following  case  is  worthy  the 
attention  of  the  surgeon,  as  it  shows  us  how  careful  we  should  be 
in  meddling  with  morbid  growths  of  long  standing,  without  being 
fully  satisfied  as  to  their  nature  and  the  place  from  which  they 

A  female,  aged  about  50,  whose  brother  I  subsequently  heard 
had  died  of  cancer,  consulted  roe  some  years  ago  on  account  of  a 
polypous  growth  in  the  right  ear,  attended  with  a  remarkably  fe- 
tid discharge  of  many  years'  duration.  She  had  an  unhealthy  look, 
and  complained  occasionally  of  giddiness,  loss  of  rest,  and  sick- 
ness of  stomach.  The  otorrhoea  having  increased  considerably  of 
late,  she  was  anxious  to  have  it  removed  if  possible.  The  meatus 
was  filled  with  a  large  reddish-brown  flabby  polypus,  much  darker 


in  colour  than  I  had  ever  seen  before.  On  examination  I  found 
it  firmly  attached  to  the  lower  and  posterior  wall  of  the  external 
meatus,  and  I  could  not  lift  it  up  or  pass  a  probe  round  it,  as  can 
generally  be  effected  in  ordinary  cases  of  polypus,  no  matter  of 
how  long  standing.  Neither  did  it  present  the  circular  protube* 
ranee  which  forms  in  cases  of  fibrous  polypus  as  soon  as  the  mor- 
bid growth  has  cleared  the  meatus  and  commenced  to  mould  itself 
into  the  shape  of  the  external  aperture.  It  was  not  possible  to 
examine  the  canal,  so  completely  did  the  morbid  growth  fill  it  up, 
bat  a  probe  could  be  passed  with  facility  all  round  its  upper  and 
anterior  surface.  These  were  the  only  symptoms  which  presented 
when  I  first  saw  her.  She  stated  that  she  had  latterly  suffered 
firom  pain  in  the  ear,  and  that  upon  several  occasions  during  the 
past  year  pieces  of  the  polypus  had  come  away.  Finding  it  im- 
poesible  to  pass  a  snare  round  it,  I  removed  a  portion  of  it  with  a 
aoissors,  and  the  hsBmorrhagc  which  followed  was  inconsiderable. 
Subsequently  I  attempted  to  lessen  the  growth  by  the  application 
of  nitrate  of  silver  applied  to  its  surface,  and  also  by  passing  a  small 
sharp-pointed  probe,  coated  with  the  caustic,  through  its  surface. 
Constitutional  treatment  calculated  to  improve  the  patient's  health 
was  not  neglected ;  and  for  a  short  time,  the  local  appearances 
improved,  but  I  was  never  able  to  clear  the  meatus  of  the  morbid 
growth.  My  attention  was  soon  attracted  by  the  rapid  progress  of 
the  fungoid  mass,  which  increased  almost  as  quickly  as  it  was  re- 
moved. In  the  course  of  a  month  the  serious  nature  of  the  disease 
manifested  itself  The  growth  from  the  meatus  assumed  a  livid 
unhealthy  colour.  The  auricle  was  pressed  forward  and  outward 
by  a  fluctuating  tumour  over  the  mastoid  process.  This  I  opened, 
and  a  quantity  of  dark-coloured  foetid  matter  was  evacuated,  and 
considerable  relief  experienced  for  a  short  time.  Paralysis  of  that 
side  of  the  face  next  appeared ;  several  large  abscesses  formed  along 
the  course  of  the  mastoid  muscle;  well-marked  rigors  ensued,  and 
ike  general  health  gave  way,  the  characters  of  malignant  disease 
being  strongly  marked  in  the  countenance.  Convulsions,  followed 
by  long  fits  of  coma,  ensued,  and  the  pain  at  times  was  most  excru- 
ciating. The  post-aural  and  infra-aural  regions  rapidly  enlarged ; 
the  integuments  of  the  mastoid  region  gave  way,  and  a  large 


fungoid  mats  sprouted  theie&om,  which,  in  a  few  days,  attained 
the  size  of  a  lemon.  The  footor  was  the  most  intolerable  and  ack- 
ening  I  ever  smelled,  and  death  put  an  end  to  her  sufferings  in 
about  three  weeks  after  the  external  appearance  of  the  fungus, 
which  presented  all  the  characters  of  true  malignant  disease.  I 
was  unable  to  obtain  a  post-mortem  examination. 

Whether  benign  disease  can,  by  interference,  be  converted 
into  malignant,  has  not  yet  been  decided  by  pathologists.  Where 
the  disease  originated  in  this  case,  it  is  not  possible  to  determine; 
eventually,  however,  it  must  have  engaged  all  the  cavities  and 
structures  of  the  ear.  The  only  point  in  which  this  case  differed 
from  one  of  ordinary  polypus,  resulting  from  chronic  inflammation 
and  otorrhoea,  when  I  first  saw  it,  was  in  the  attachment  of  the 
growth  to  the  external  and  posterior  lip  of  the  meatus. 

The  following  case,  for  the  particulars  of  which  I  am  indebted 
to  Mr.  Ciisack,  occurred  in  this  city  in  1843.  It  was  originally 
published  in  my  essay  on  otorrhoea,  but  is  so  similar  in  many  re- 
spects to  the  foregoing  that  I  insert  it  here. 

An  apparently  healthy  boy,  seven  years  of  age,  was  brought 
to  him  on  account  of  a  discharge  from  the  external  meatus.  Upon 
examination,  a  small  polypus  was  discovered  in  the  passage;  this 
was  removed,  but  on  the  third  day  following  it  was  found  to  have 
grown  as  large  as  ever ;  it  was  again  repeatedly  removed,  and  the 
usual  slightly  astringent  washes  were  had  recourse  to  in  the  inte- 
rim. This  polypus  or  fungous  growth  did  not  present  anything 
remarkable  except  the  extraordinary  power  of  being  reproduced 
in  a  day  or  two,  on  which  account  it  was  no  longer  attempted 
to  be  destroyed,  but  a  more  palliative  mode  of  treatment  was  had 
recourse  to.  Not  long  after,  the  child  was  suddenly  seized  with 
an  epileptic  fit ;  and  then,  on  closely  examining  the  ear,  a  fluctu- 
ating point  was  discovered  over  the  mastoid  process;  this  was 
instantly  cut  down  upon,  and  the  opening  gave  exit  to  a  laige 
discharge  of  pus.  It  was  then  found  that  the  cavity  which  con- 
tained this  matter  communicated  by  a  fistulous  opening  with  the 
external  auditory  tube ; — a  fungous  mass  almost  immediately 
sprouted  through  the  incision ;  the  parts  in  front  and  all  round  the 
ear  became  swollen,  and  had  that  peculiar  boggy  keX  to  the  touch, 


which  left  but  little  doubt  regarding  the  malignant  nature  of  the 
disease.  The  original  aural  polypus  remained  as  before,  but,  from 
the  struggles  of  the  child  and  the  condition  of  the  parts,  at  no 
one  period  was  it  possible  to  learn  with  accuracy  the  state  of  the 
tympanum.  Repeated  attacks  of  epilepsy,  each  increasing  in  vio- 
lence, and  the  intervals  shortening  in  duration,  followed  quick 
upon  this  deplorable  condition,  and  death  soon  closed  the  scene. 

Upon  examination  it  was  discovered  to  be  a  well-marked  case 
of  osteosarcoma  of  the  petrous  and  mastoid  portions  of  the  tem- 
poral bone.  The  petrous  portion  in  particular  was  enormously 
enlarged,  and  so  softened  as  to  be  capable  of  being  cut  with  a 
knife.  The  whole  presented  a  large  fungous  mass,  which,  how- 
ever, did  not  engage  that  portion  of  the  brain  which  lay  upon  it. 
All  traces  of  the  internal  ear  had  been  obliterated.  There  can,  I 
think,  be  little  doubt,  but  that  in  this  case  the  original  disease 
was  seated  in  the  bone,  and  that  the  aural  discharge  and  fungus 
were  but  secondary  morbid  appearances. 

Dr.  Hutton  has  just  informed  me  that  he  had  lately  under  his 
care  a  case  of  chimney-sweepers'  cancer  of  the  external  ear. 

A  fortnight  after  the  note  of  Dr.  Morgan's  case  of  exostosis, 
referred  to  at  page  205,  I  saw  Mr.  B.,  whose  treatment  had,  in  the 
interim,  consisted  in  leeching  the  meatus,  and  the  internal  admi- 
nistration of  minute  doses  of  the  bichloride  of  mercury.  The  im- 
provement was  truly  astonishing :  the  protuberances  in  the  left 
ear  had  lessened  considerably,  and  the  hearing  was  nearly  restored 
on  that  side. 

We  sometimes  meet  with  small,  white,  round  bodies,  the  size 
of  millet  seeds,  in  the  walls  of  the  meatus,  similar  to  those  frequently 
seen  about  the  eyelids. 

In  describing  the  diseases  of  the  auricle,  I  should  have  men- 
tioned **  dislocation,"  of  which  a  remarkable  example  presented  at 
South  Carolina,  in  which  the  auricle  was  detached  from  its  seat, 
and  carried  downwards  on  the  surface  of  an  enormous  pendulous 
tumour.     (See  London  Medical  Repository,  1816.) 




Anatomy  of  Membrana  Tympani. — Its  Congenital  Malformations. — Injuries  of:  Rap- 
ture. — Inflammations  :  Acute ;  Rheumatic  Otitis. — Subacute :  Syphilitic ;  Gouty. — 
Senile  Deafness. — Strumous ;  with  Ophthalmia. — Exanthematous ;  Typhoid. — Chro- 
nic Thickening  and  Morbid  Deposits  in  Membrane. — Cutaneous  Diseases. — Collapse, 
with  Loss  of  Vibration Operation  of  Perforation Ulceration ;  Apertures  in  Mem- 
brane; Total  Destmction  oC — Artificial  Membrana  TympanL 

THE  memhrana  tympanic  or  drum-head,  separates  the  external 
meatus,  at  the  extremity  of  which  it  is  placed,  from  the  ca- 
vity of  the  tympanum  ;  so  that,  from  its  position  as  well  as  the 
anatomical  connexion  of  its  structures,  it  must  partake  of  the 
diseases  of  both  cavities  independent  of  those  peculiar  to  itself.  It 
is  a  thin,  semitransparent,  dry  membrane,  of  an  irregular  oval 
shape,  varying  in  size  as  much  as  the  cornea,  but  generally  mea- 
suring about  eight-twentieths  of  an  inch  in  its  longest  diameter, 
which  is  in  a  diagonal  line  from  above  forwards  and  downwards. 
It  is  placed  obliquely  from  above  downwards,  and  somewhat 
from  before  backwards  and  outwards,  and  set  in  a  well-marked 
groove  upon  an  elevated  ridge,  at  the  tympanal  margin  of  the 
bony  meatus,  like  the  crystal  on  the  besil  of  a  watch.  In  foetal 
life  this  tympanic  ring  is  a  separate  and  distinct  portion  of  the 
temporal  bone,  and  does  not  become  altogether  incorporated 
with  it  until  some  time  after  birth.  It  is  produced  from  a  sepa* 
rate  and  distinct  point  of  ossification,  and  may,  therefore,  be  re- 
garded as  a  fourth  division  of  the  temporal  bone  superadded  to 
those  already  enumerated  at  page  150.  From  this  ring  grows  the 
osseus  meatus  auditorius  externally,  and  also  a  portion  of  the  floor 
of  the  cavity  of  the  tympanum  internally.  This  circle  is  never 
completed,  as  may  be  seen  by  examining  a  section  of  the  tempo- 
ral bone,  made  through  the  tympanum,  immediately  behind  the 
groove  for  the  attachment  of  the  membrane.  It  remains  deficient 
superiorly,  where  the  malleus  joins  the  memhrana  tympani,  and 


at  which  point  the  head  of  that  bone  lies  in  the  superior  sinus  of 
the  tympanum.  If  we  examine  a  number  of  temporal  bones,  we 
will  find  the  groove  for  the  meuibrane  deepest  at  the  lower  and 
back  part,  and  least  marked  above,  towards  the  part  where  the 
ring  is  generally  deficient. 

The  manubrium,  or  handle  of  tlie  malleus,  is  enclosed  for  about 
three-iburths  of  its  length  between  the  laminae  of  the  mcmbrana 
tympani,  which  are  partially  inserted  into  it.  This  process  of  the 
hammer-bone  serves  to  support  and  also  to  preserve  the  peculiar 
carvature  of  the  membrane,  as  well  as  to  convey  to  tlie  hibyrinth 
the  vibrations  of  sound  which  impinge  upon  it.  At  birth  the  tym- 
panic ring,  with  its  enclosed  membrane,  looks  obliquely  downwards 
and  slightly  outwards,  and  it  is  only  by  the  formation  of  the  floor 
of  the  tympanum  that  the  position  which  it  assumes  in  adult  life 
is  produced.  The  membrana  tympani  is  also  proportionally  larger 
in  the  fostus  than  in  the  adult.  A  knowledge  of  these  relations  is 
important  in  a  pathological  point  of  view,  as  they  show  how  easily 
disease  of  the  meatus  or  the  membrana  tympani  may  be  propagated 
to  the  neighbouring  parts. 

Viewed  through  the  speculum,  with  a  stream  of  clear,  direct 
sunlight  upon  it,  the  membrana  tympani  is  of  a  greyish  hue,  and 
semi  transparent  consistence  ;  and  presents  externally  an  irregu- 
larly curved  surface,  as  also  difierent  degrees  of  density,  polish, 
and  tension.  It  is  divided  by  a  white  streak,  thick  above  and  nar- 
row below,  except  at  its  extremity,  which  is  slightly  enlarged  and 
indented  into  a  navel-like  depression.  This  white  opaque  line  is 
the  manubrium  of  the  malleus,  proceeding  from  the  upper  attach- 
ment of  the  membrane  downwards,  somewhat  backwards  and  a 
little  inwards  to  a  point  slightly  below  the  centre  of  the  mem- 
brane, and  thus  divides  it  into  an  anterior,  a  posterior,  and  an  infe- 
rior portion.  But  the  exact  situation  of  this  bone,  and  consequently 
the  relative  proportions  of  the  parts  which  it  divides,  present  great 
diversity.  The  anterior  part  of  the  membrane  is  thin, — almost 
transparent,  or  as  clear  as  fine  gold-beater's  skin, — highly  polished, 
and  generally  convex — a  speck  of  bright  light  being  reflected  from 
its  most  prominent  part.    This  may  be  called  the  anterior  vibrat- 



ing  portion.  In  many  cases  the  short  process  of  the  malleus  may 
be  seen  as  a  small  round  dot  above  the  manubrium  where  the  mem- 
brane curves  oflf  into  the  roof  of  the  meatus.  The  bottom  of  the 
meatus,  it  should  be  remembered,  is  funnel-shaped,  the  broad  end 
of  the  funnel  being  towards  the  tympanum. 

When  the  centre  of  the  membrane  is  under  examination,  its  an- 
terior attachment,  behind  the  sharp  curve  of  the  meatus,  cannot 
at  the  same  time  be  seen,  nor  until  the  tubular  speculum  is  turned 
towards  it,  and  the  head  of  the  person  examined  is  brought  into 
the  proper  angle ;  and  the  same  remark  holds  good,  except  in  cases 
of  very  large  meatus,  with  respect  to  the  posterior  margin ;  the 
superior  and  inferior  attachments  are  more  easily  observed;  but, 
by  rotating  the  speculum,  and  altering  the  head  from  side  to  side, 
we  can  bring  in  succession  each  portion  of  the  membrane  into 
view.  The  relative  size  of  each  portion  of  the  membrane  varies 
in  different  individuab.  In  making  this  examination  the  tube 
should  not  be  inserted  much  beyond  the  middle  of  the  mea- 
tus. Below  and  behind  the  malleus  the  membrane  is  also  thin, 
clear,  and  glistening,  but  not  quite  so  diaphanous.  Beneath 
the  point  of  the  malleus  it  is  flaty  and  behind  it  rather  concave^ 
but  not  always  so.  These  portions  do  not  usually  present  in 
their  normal  state  spots  of  reflected  light.  Superiorly,  from  about 
the  upper  half  of  the  malleus,  the  membrane  becomes  gradu- 
ally denser  until  it  is  quite  white  ;  it  also  forms  concave  curves 
from  the  upper  part  of  the  malleus,  the  posterior  one  being  deepest 
and  whitest.  Above,  the  membrane  forms  a  gradually  vaulted 
curve  into  the  roof  of  the  external  auditory  canal,  with  the  lin- 
ing of  which  it  is  imperceptibly  blended  ;  while  in  front,  below 
and  partly  behind,  there  is  a  sharp,  well-defined  line  of  demarca- 
tion between  it  and  the  meatus,  and  sometimes  a  slight,  whitish 
thickening,  which  in  disease  and  in  some  old  persons  resembles 
the  arcus  senilis,  except  that  in  the  cornea  there  is  always  a  nar- 
row clear  space  between  the  opacity  and  the  sclerotic.  In  some 
persons  there  is  a  slight  purse-like  projection  of  the  membrane 
near  its  upper  attachment  and  behind  the  tubercle  of  the  malleus 
— the  "mcmbrana  fiaccida**  of  Sharpnell — rudimentary  in  man. 


but  well  developed  in  some  of  the  lower  animals.  The  speck  of 
light  which  is  generally  reflected  from  the  most  convex  and  pro- 
minent portion  of  the  membrane  is  not  always  in  the  centre  of  the 
anterior  part,  but  is  often  seen  beneath  it.  If  a  horizontal  section 
of  the  membrana  tympani  be  made,  it  will  present  somewhat  the 
form  of  an  italic  ( /*),  the  middle  point  being  the  circular  flattened 
extremity  of  the  manubrium  of  the  malleus. 

If  the  patient  under  examination  inflates  the  tympanum  after 
the  manner  described  at  page  64,  without  moving  the  head,  alter- 
ing the  position  of  the  speculum,  or  in  any  way  deranging  the 
light,  the  whole  of  the  anterior  and  part  of  the  lower  portion  of 
the  membrana  tympani  is  bulged  outwards,  and  the  speck  of  light 
appears  as  if  spread  over  a  larger  surface,  or  is  entirely  lost  for  the 
moment.  Whether  the  membrane  is  then  rendered  more  or  less 
tense  I  cannot  satisfactorily  state.  In  some  cases  a  slight  eleva- 
tion or  outward  pressure  of  the  malleus,  and  even  of  the  whole 
membrane,  may  be  observed.  If  the  inflation  be  continued,  the 
upper  white  portion  frequently  becomes  red,  and  vessels  can  be 
seen  at  times  spreading  from  it  along  the  sides  of  the  malleus. 

Cheat  diversity  of  opinion  exists  among  authors  with  respect 
to  the  curvature  and  general  appearance  of  the  healthy  membrana 
tympani.  They  almost  all,  however,  agree  in  pronouncing  it  a 
uniform  concavity ;  but  this  I  believe  to  be  a  post-mortem  appear- 
ance. One  of  the  proofs  aflforded  by  anatomists  of  the  external 
concavity  of  membrana  tympani  is, — that,  when  the  cuticular  lin- 
ing common  to  it  and  the  meatus  is  removed  entire,  and  floated  in 
water,  its  extremity  forms  a  curved  pouch  like  the  finger  of  a 
glove.  This,  however,  is  a  very  fallacious  test ;  for,  if  we  take 
the  finger  of  a  glove  and  invert  its  extremity,  so  as  to  present  a 
marked  convexity  towards  its  internal  surface,  wc  can  easily, 
either  by  blowing  into  it  or  drawing  it  through  water,  make  it 
assume  a  concave  appearance. 

Well  acquainted  as  every  person  familiar  with  the  character 
which  the  membrana  tympani  presents  upon  inflation,  it  will  ap- 
pear almost  incredible  that  Dr.  Kramer  should  believe  that  even 
a  forcible  stream  of  air  from  the  air-press  cannot  alter  its  concave 


It  is  of  great  importance  that  we  should  be  not  only  acquainted 
but  familiar  with,  the  external  appearance  of  the  membrana  tym- 
pani  in  anormal  condition ;  yet  how  many  practitioners  pass  through 
life  without  ever  having  seen  it  in  the  living  state ! — all  they  know 
of  it  being  from  description  or  preparations  shown  them  during 
their  anatomical  studies.* 

Behind  the  attachment  of  the  membrane  superiorly,  there  is 
the  head  of  the  malleus,  which  rises  above  it  into  a  large  hollow 
in  the  bone,  which  freely  communicates  with  the  mastoid  cells. 
Anteriorly,  and  somewhat  below  the  middle  line,  there  is  the 
tympanic  opening  of  the  Eustachian  tube,  opposite  the  portion 
of  membrane  most  easily  acted  upon  by  a  stream  of  air,  and  that 
where  it  most  usually  gives  way.  Below  and  behind  the  Eusta- 
chian tube  is  the  carotid  canal,  usually  perforated  in  that  part 
of  its  posterior  curve  nearest  to  the  membrana  tympani  by  a  small 
aperture  for  the  transit  of  a  vessel  which,  being  distributed  to  the 
membrana  tympani  from  so  near  and  large  a  stream,  may,  with 
its  other  plentiful  supply,  account  for  the  pulsation  which  that 
membrane  presents  in  certain  forms  of  disease.  Behind,  and 
winding  round  its  posterior  and  upper  margin,  the  aqueduct  of 
Fallopius  conducts  the  portio  dura  to  the  stylo-mastoid  foramen ; 
and  the  proximity  of  that  nerve  to  the  cavitas  tympani  and  its 
external  partition,  will  enable  us  to  account  for  the  facial  paralysis 
which  frequently  accompanies  disease  of  the  ear. 

The  structure  of  the  membrana  tympani  has  been  carefully  in- 
vestigated by  many  eminent  anatomists,  and  is  found  to  consist  of 
a  proper  fibrous  layer,  and  two  others  borrowed  from  the  neigh- 
bouring structures, — viz.,  the  epidermis  continuous  with  that  re- 
flected over  the  meatus  externally,  and  the  fine,  delicate,  mucous 
lining  of  the  tympanal  cavity — a  portion  of  the  great  gastro-pul- 
monary  investiture  prolonged  through  the  Eustachian  tube — inter- 
nally. The  tegumentary  or  external  cuticular  layer  is,  in  a  healthy 
condition,  remarkably  fine,  and  so  transparent  that  the  fibres  of 
the  layer  beneath  it  can  be  seen  distinctly  through  it ;  yet,  in  dis- 

*  In  addition  to  Uie  fore^ing  observations,  see  the  remarks  upon  the  membrana  tym- 
pani, at  pp.  10f)-7.  See  also  the  author's  description  of  this  structure  in  the  Dublin 
Quarterly  Journal  of  Medical  Science,  vol  xxiv.  p.  421.      1844. 


or  by  decomposition,  it  is  rendered  white  and  thick,  and  can 
frequently  be  detached  in  an  unbroken  scale.  Within,  the  mucous 
linii^g  is  so  fine  that  it  is  discerned  with  difEcuIty,  yet  in  disease 
it  becomes  thickened,  vascular,  villous,  and  even  pulpy. 

The  middle  or  proper  fibrous  layer  is  composed  of  two  lamina:, 
— a  radiate  externally,  a  circular  internally ;  in  addition  to  which 
there  is  a  cartilaginous  or  ligamentous  ring,  already  referred  to  at 
page  213,  which  is  somewhat  denser  and  whiter  than  the  rest  of 
the  membrane,  and  surrounds  its  attachment,  except  at  the  upper 
portion  where  the  osseous  groove,  into  which  it  is  inserted,  is  de- 
ficient. This  cartilaginous  circle  is  continuous  with,  and  inti- 
mately united  with  the  periosteum,  and  the  radiating  fibres  of  the 
external  layer  are  inserted  into  it.  In  the  living,  healthy  car,  it 
can  often  be  distinguished  from  the  rest  of  tlie  membrane,  but  in 
disease  it  becomes  very  manifest,  and  frequently  presents  a  bnght 
vascular  zone,  when  the  rest  of  the  membrane  is  unaffected.  It 
is  also  the  seat  of  that  inferior  crescentic  opacity  described  in  the 
analysis  of  the  Registry,  at  page  136.  The  fibres  of  the  external 
radiating  lamina  proceed  from  the  sides  and  the  extremity  of  the 
malleus  to  the  cartilaginous  ring  for  about  the  inferior  half  of  the 
membrane.  Superiorly  the  fibres  pass  across  or  are  external  to 
the  upper  portion  of  the  malleus,  and  are  inserted  into  the  perios- 
teum of  the  meatus.  The  circular  lamina  passes,  for  the  most  part, 
behind  the  handle  of  the  malleus,  and  is  united  by  fine  cellular 
tissue  to  the  radiating  layer  in  front  of  it.  It  is  unconnected  with 
the  cartilaginous  ring,  but  is  said  to  be  continuous  with  the  pe- 
riosteal lining  of  the  tympanal  cavity.* 

*  Mr.  Toynbee,  the  latest  autiiority  upon  the  subject,  has,  in  an  Appendix  to  his  pa- 
per "On  the  Membrana  Tj'mpani  of  the  Human  Ear,"  in  the  Philosophical  Transactions  for 
1851,  described  the  membrana  tympani  as  composed  of  six  laminae, — viz.,  the  epidermoid, 
or  coticular;  the  dermoid,  a  distinct  and  complete  lamina  of  membrane  which  is  oonti- 
naoQS  wiUi  the  dermoid  layer  of  the  meatus,  and  which,  from  its  containing  numerous 
blood-vessels,  might  be  called  the  vascular  layer ;  the  external  radiating  lamina  of  the 
fibrous  layer,  continuous  with  the  periosteum  of  the  meatus ;  the  internal  circular,  conti- 
nuous with  that  of  the  tympanum ;  the  mucous  lining;  and  finally  the  epithelium  cover- 
ing that  structure,  in  addition  to  the  circular  fibro-cartilagiuous  portion  already  described. 
But  these  are  too  minute  subdivisions  for  practical  purposes. 


Sir  Everard  Home  and  others  maintained  that  the  membntna 
tympani  was  muscular,  but  Bubeequent  observers  have  not  con- 
finned  that  idea ;  and  ProfeBsor  Harriaon,  in  his  dissection  of  the 
ear  of  an  elephant,  that  died  some  years  ago  in  the  Zoological 
Giardens,is  of  opinion  that  the  membrane  is  not  muscular.  Rivinus, 
and  some  of  the  older  anatomists,  conceived  that  a  natural  aperture 
existed  in  the  membrana  tympani,  but  thiaerrorhas  been  corrected 
by  modem  investigation.  That  many  persons  have,  however,  a 
perforate  membrana  tympan!  without  experiencing  any  inconvc* 
aience  from  it,  is  well  known;  such  persons  are  generally  able  to 
force  tobacco  smoke  through  the  external  meatus.  The  thinnest 
portions  of  the  membrane  are  about  midway  between  the  points 
of  the  malleus  downwards  and  forwards  in  the  anterior  portion, 
and  downwards  and  backwards  in  the  posterior  portion.  It  is, 
therefore,  in  one  or  other  of  these  spots  that  we  generally  find  it 
perforated  by  either  accident  or  disease. 

The  membrana  tympani  is,  in  a  state  of  health,  highly  sensitive, 
the  slightest  touch  producing  the  most  acute  pain.  Mr.  Wharton 
Jones  says  it  receives  "  a  nerve  from  the  third  division  of  the 
fifth,  which  has  communications  with  filaments  from  the  chorda 

Thin,  dry,  and  almost  transparent  as  the  membrana  tympani 
appears  in  the  healthy  living  state,  it  can,  by  fine  injection,  be 
rendered  a  complete  vascular  net-work,  and  the  same  appearance 
may  b«  perceived  in  disease,  modified  according  to  tlie  peculiar 
structure  or  special  vessels  engaged.  Arnold, 
in  his  magnificent  lithographic  plates,  has 
given  figures  of  the  veins  and  arteries  of  the 
membrana  tympani,  from  the  latter  of  which  1 
I  have  had  the  accompanying  accurate  wood- 
engraving  copied."  Soemmerring  has  also 
faithfully  represented  the  arteries  of  the  tym- 
panal membrane  in  the  normal  condition  as 
two  long  vessels  proceeding  from  above  downwards  and  backwards 

•  TibDlK  AnmUmicm;  FsBcii-uliu  Secondn*;  T«b.  v.,  fig.  38.  The  Dnvtng,  re- 
ducal  •bmrt  one-third,  hu  been  copKd  utd  engravn)  with  great  fldditr  by  Mr.  Ohlbun. 


along  the  course  of  the  handle  of  the  hammer,  and  branching  on 
either  side  into  the  anterior  and  posterior  vibrating  thin  portions 
of  the  membrane.  The  outer  circle  in  the  woodcut  is  the  bony 
ring  upon  the  right  side  seen  from  within  in  an  infant,  and  the 
central  body  is  the  cut  off  extremity  of  the  manubrium.  The 
large  artery  proceeding  from  above  downwards  is  the  tympanic 
branch  of  the  stylo-mastoid,  which  anastomoses  freely  and  by 
large  trunks  at  the  upper  deficiency  of  the  ring,  with  vessels  re- 
ceived from  the  internal  maxillary  through  the  Glasserian  fissure. 
These  vessels,  uniting,  send  a  considerable  trunk  along  the  attach- 
ment of  the  manubrium ;  but  in  the  living  state,  when  the  mem- 
brane is  irritated,  two  or  three  vessels  can  generally  be  seen 
coursing  downwards  on  each  side  of  the  bone,  and  looping  round 
its  extremity.  This  tympanic  artery  then  radiates,  as  shown  in 
the  cut,  towards  the  periphery  of  the  membrane,  where  it  inoscu- 
lates so  freely  as  to  form  a  circumferential  vascular  plexus  with 
the  tympanic  branch  of  the  deep  auricular  which  is  given  off  at 
the  angle  between  the  temporal  and  internal  maxillary.  This 
latter  vessel  reaches  the  membrane  at  its  lower  curvature,  and 
forms  that  crescentic  red  appearance  frequently  seen  in  partial 
inflammation  of  the  lower  portion  of  the  membrana  tympani. 
Both  these  vessels  ramify  on  the  external  surface  of  the  proper 
fibrous  layer,  and  being  continuous  with  the  vascular  supply  of  the 
external  meatus  and  the  auricle,  show  how  much  more  effectual 
local  depletion  made  round  the  aperture  of  the  auditory  canal 
must  be  in  relieving  turgescence  of  the  vessels  of  the  membrana 
tympani  than  when  applied  on  the  mastoid  process,  as  formerly  in 
use.  Towards  the  upper  portion,  in  particular,  we  can  frequently 
trace  those  vessels  which  ramify  about  the  malleus  into  the  vaulted 
roof  of  the  meatus. 

That  the  mucous  lining  of  the  tympanic  cavity,  reflected  over 
the  back  of  the  membrana  tympani,  though  so  thin  and  transpa- 
rent in  health  as  to  be  demonstrated  with  difficulty,  becomes  in 
disease  suddenly  and  intensely  vascular,  I  have  had  maiiy  oppor- 
tunities of  determining.  In  such  cases,  the  proper  fibrous  layer, 
as  well  as  the  cuticular  envelope  of  the  membrana  tympani  re- 
main polished  and  as  transparent  as  natural,  while  the  inflamed 


mucous  lining  may  be  seen  through  these  structures  of  a  pinkish 
colour,  somewhat  like  that  observed  on  the  under  surface  of  a 
monthly  rose-leaf  The  arterial  supply  of  this  lamina  is  obtained 
from  a  variety  of  sources,  viz.,  the  stylo-mastoid,  the  temporal, 
the  internal  maxillary,  the  meningeal,  and  the  internal  carotid 
arteries ;  the  latter  sends  its  twig  through  the  small  hole  in  its 
bony  canal,  referred  to  at  page  214.  When  the  proper  fibrous 
membrane  is  inflamed,  it  will  sometimes  present  one  uniform  sheet 
of  bright  red ;  in  addition  to  which  I  have  frequently  seen  and 
pointed  out  to  my  pupils  several  small  straight  vessels  superficial 
to  the  general  redness,  and  radiating  from  the  centre  towards  the 

During  life  these  vascular  arrangements  can  only  be  seen  in 
disease,  and  with  a  stream  of  clear  bright  sunlight  directed  upon 
the  membrana  tympani.  Having  brought  the  membrane  fairly 
within  the  field  of  the  speculum,  a  magnifying  glass  held  in  the 
proper  position  will  not  only,  by  enlarging  the  parts  under  inspec- 
tion, but  also  by  concentrating  the  light  upon  them,  materially 
assist  our  view.  I  lately  showed,  that  when  the  membrana  tym- 
pani has  been  perforated,  the  globule  of  air,  or  mucous  bubble, 
entangled  in  the  aperture  pulsates  synchronously  with  the  heart 
and  arteries.l  That  this  motion  is  imparted  to  the  membrane  by 
the  copious  vascular  supply  from  so  many  large  adjacent  sources, 
I  have  had  within  the  last  few  days  an  opportunity  of  deter- 
mining ;  for,  having  placed  a  piece  of  cotton  moistened  with  oil 
within  the  remnant  of  the  membrana  tympani,  which,  except  at 
the  upper  portion,  scarcely  advanced  within  the  tympanic  groove 
of  the  meatus,  I  was  astonished  to  find  that  it  pulsated  in  like 
manner  with  the  membrane,  receiving,  I  presume,  the  impulse 
from  the  arterial  circle  still  remaining  in  connexion  with  the 
groove  to  which  that  structure  had  been  originally  attached. 

*  In  cases  of  long-cuntinued  iuflammation  of  the  iris,  large  red  v^sels  can  be  seen 
ramifying  on  its  surface ;  but,  in  acute  cases,  I  have  lately  been  able  to  determine,  with 
the  aid  of  a  strong  magnifying  glass,  that  the  rusty  or  brownisli-red  unelevated  spots  seen 
on  the  corneal  aspect  of  that  membrane  pruve  to  be  nothing  more  than  congeries  of  ves- 
sels carrying  red  blood. 

t  See  a  case  of  Otorrhoea  with  perforation,  and  description  of  a  new  diagnostic  symptom, 
in  the  Medical  Times  and  Gazette  for  27th  March,  1852,  No.  91. 


The  membrana  tympani  is  in  health  the  drycst  membrane  in  the 
body, — is  it  hygroraetric,  or  capable  of  imbibing  moisture  from 
the  surrounding  atmosphere,  and  thus  becoming  more  or  less 
tease,  according  to  the  medium  in  which  it  is  placed?  I  believe 
it  isy  although  it  is  difficult  to  offer  proof  thereof.  Certainly  pa- 
tients labouring  under  partial  deafness  affirm,  that  on  dull  moist 
days,  or  in  damp  weather,  they  cannot  hear  so  well  as  when  the 
atmosphere  is  dry  and  clear.  How  much  of  this  depends  upon 
the  atmosphere  considered  as  a  medium  for  conducting  sound,  or 
upon  the  condition  of  the  membrana  tympani  itself,  we  have  yet 
to  learn.  There  are  other  subjects  connected  with  the  state  of 
tension,  amount  of  curvature,  and  degree  of  flattening  or  collapse 
which  the  membrane  occasionally  presents,  that  might  be  consi- 
dered here,  but  that  they  properly  belong  to  the  pathology  of  this 

I  have  dwelt  thus  long  upon  the  anatomical  characters  of  the 
membrana  tympani  because  it  is  that  part  of  the  ear  least  known  to 
students  or  practitioners ;  and  because  in  it  will,  according  to  my  ob- 
fK*rvationB,  be  found  characteristics  of  disease  and  pathological 
changes  from  the  normal  structure,  sufficient  to  account  for  at  least 
two-thirds  of  the  cases  of  impaired  hearing,  independent  of  me- 
chanical impediments  from  wax,  and  the  inflammations  presenting 
otorrhcea  which  occur  in  practice.  It  is  true  that  the  pathologi- 
cal condition  or  amount  of  disease  seen  upon  the  external  surface 
of  the  membrana  tympani  is  frequently  insufficient  to  account 
for  the  degree  of  deafness;  still  such  changes,  which  are  visible 
to  tHe  eye,  are  indicative  of  certain  conditions  of  the  middle  ear 
which  are  beyond  our  ken, — in  the  same  manner  as  the  state  of 
the  cornea  and  iris,  which  we  do  see,  are  characteristic  of  certain 
changes  in  the  parts  beyond  (the  choroid  and  retina)  which  have 
proved  destructive  to  vision,  which  we  do  not  see ;  and  the 
amount  of  mechanical  defect  is  seldom  commensurate  with  the 
extent  of  mischief  in  the  scnsient  parts  beyond. 


Where  the  external  auditory  canal  or  the  tympanum  is  deficient, 
or  closed  by  bone,  the  membrana  tympani  must,  as  a  matter  of 


course,  be  wanting.  Cases  have  been  recorded  in  which  a  false 
membrane  covered  the  membrana  tympani.  The  only  instance  I 
have  seen  of  irregularity  in  the  membrana  tympani  consisted  in 
malposition  of  the  attachment  of  the  malleus.  Upon  examining 
the  ears  of  the  pupils  in  the  Institution  for  the  Deaf  and  Dumb  at 
Claremont,  I  observed  two  instances  in  which  the  manubrium,  in- 
stead of  occupying  its  usual  position,  passed  forwards  towards  the 
lower  and  anterior  attachment  of  the  membrane.  In  a  third,  the 
membrana  tympani  was  one  uniform,  concave  membrane,  without 
the  slightest  vestige  of  any  of  the  ossicles  within  it,  and  I  have 
seen  a  similar  case  in  private.  It  is  believed  that  the  hole  which 
Rivinus  considered  as  a  normal  formation  was,  in  the  instances 
which  he  examined,  an  accidental  malformation. 


Injuries  of  the  membrana  tympani^  independent  of  those  arising 
from  inflammation  or  its  consequences,  may  be  caused  by  pene- 
trating instruments  or  foreign  bodies  passing  through  from  the 
external  meatus;  rupture  in  whole  or  in  part  by  external  violence, 
such  as  fracture  of  the  temporal  bone,  blows  on  the  side  of  the 
head,  or  falls,  &c. ;  and  loud  sounds,  concussions,  or  the  sudden 
impression  of  a  stream  of  air  from  within  the  tympanum,  when 
the  membrane  is  in  a  particular  state  of  tension,  and,  perhaps,  I 
should  add,  of  dryness.  I  have  already  given  instances  of  foreign 
bodies  passing  through  the  membrana  tympani ;  and  many  cases 
have  been  recorded  of  the  membrane  having  been  perforated  by 
the  accidental  introduction  of  penetrating  instruments,  or  even  pins 
and  ear-pickers.  Sir  Astley  Cooper  relates  a  case  of  laceration  of 
the  membrana  tympani  caused  by  a  box  on  the  side  of  the  head, 
extending  from  above  downwards  across  the  entire  membrane. 
When  bleeding  from  the  ears  occurs  in  hooping  cough,  sudden 
violent  congestion,  or  strangulation,  I  suppose  the  haemorrhage 
comes  from  the  middle  ear  through  the  burst  membrana  tympani. 

Case  No.  58  in  the  Registry  is  that  of  a  man  aged  40,  who, 
in  a  fit  of  intoxication,  fell  against  the  street  railing,  and  was  car- 
ried home  insensible.  He  had  considerable  haemorrhage  from  the 
left  ear  both  at  the  time  and  for  several  hours  after.     Having  lost 


the  hearing  completely  on  that  side,  he  applied  at  the  hospital  one 
month  suhaequent  to  the  accident.  The  membrana  tympani  was 
rather  opaque,  and  a  well-marked  cicatrix  running  from  above 
downwards,  anterior  to  the  malleus,  could  be  observed ;  it  was  of 
a  dense  white  colour,  but  became  red  upon  the  tympanum  being 
inflated.  A  second  case,  that  of  a  female  aged  30,  No.  122  in 
Registry,  presented  somewhat  the  same  appearance  from  a  blow 
on  the  right  ear,  followed  by  haemorrhage,  but  the  accident  had 
occurred  three  years  before  I  saw  her.  The  subject  of  haimorrhage 
from  the  ear  not  having  been  yet  sufficiently  investigated  in  a  pa- 
thological or  a  medico-legal  point  of  view,  a  wide  field  for  inquiry 
into  this  subject  still  exists.  Bleeding  from  the  ear  has  been  re- 
marked in  persons  ascending  to  great  elevations,  as  well  as  in 
descending  in  diving-bells;  and  professional  divers,  likewise,  ex- 
perience the  same  affection.  Diving  to  any  depth  is  a  frequent 
caase  of  rupture  of  the  membrana  tympani;  I  have  seen  two  in- 
stances in  which  it  occurred.  A  gentleman,  when  in  a  warm  bath, 
having  allowed  some  of  the  water  to  get  into  his  external  meatus, 
thrust  in  his  finger  forcibly,  with  the  intention  of  dislodging  it, 
when  he  felt  something  burst  in  his  ear,  and  he  immediately  per- 
ceived the  water  in  his  throat.  I  saw  him  a  short  time  after,  when 
the  parts  were  considerably  inflamed.  There  was  a  small  rupture 
in  the  inferior  portion  of  the  membrane.  The  gentleman  was  for 
a  long  time  after  the  accident  in  the  habit  of  applying  a  drop  of 
fluid  with  the  point  of  his  finger  into  the  meatus,  and  letting  it  fall 
into  the  aperture  in  the  membrana  tympani, — a  practice  which 
many  persons,  with  perforations  in  the  lower  portion  of  the  mem- 
brana, are  familiar  with.  A  lady,  whose  ears  I  had  examined  a 
few  days  previously,  and  in  whom  the  membrana  tympani  was  re- 
markably thin  and  dry,  sent  for  me  to  say  that,  while  blowing  her 
nose  violently,  something  had  suddenly  burst  in  her  ear.  Upon 
inspection,  an  hour  after  the  accident,  I  found  an  aperture  in  the 
anterior  vibrating  portion  of  the  membrane  of  a  triangular  shape, 
with  lacerated,  everted  edges ;  a  slight  streak  of  blood  surrounded 
the  rent;  there  could  be  no  doubt  as  to  tlie  cause  of  the  rupture. 

Any  loud,  sharp  report,  such  as  that  from  a  piece  of  artillery, 
may  cause  temporary,  or  even  permanent,  deafness,  rupture  of 


tlic  membrana  tympani,  and  haemorrhage  from  the  meatus.  Ar- 
tillery recruits  frequently  suffer  from  bleeding  from  the  ears,  but 
the  exact  cause  has  not  been  yet  fully  ascertained. 

Surgeon  Thornton  of  the  Royal  Artillery,  to  whom  I  addressed 
a  letter  on  the  subject  of  haemorrhage,  tinnitus,  and  deafness  in 
gimners,  writes  to  me  as  follows: — **  Many  of  the  men  state  that 
they  have  seen  haemorrhage  occur,  but  it  is  not  so  frequent  as  is 
supposed  ;  dulness  of  hearing  is,  however,  very  common,  espe- 
cially among  old  gunners.  The  effect  of  position,  with  reference 
to  the  gun,  is  peculiar, — those  men  who  stand  nearest  the  muz- 
zle feel  the  report  most,  but  all  who  are  to  leeward  suffer  more 
than  those  to  windward.  Braids  ordnance  ring  louder  and  make  a 
sharper  report  than  iron  guns, — the  usual  effect  of  which,  as  I  have 
myself  experienced,  is  that  of  receiving  a  smart  blow  upon  the 
tympanum ;  this,  however,  soon  passes  off,  and  leaves  a  singing 
or  tingling  sensation  in  the  ear  for  two  or  three  days.  Another 
peculiar  sensation  is  that  of  having  water  in  the  ear,  as  if  after 
bathing.  After  some  practice  the  ear  becomes  accustomed  to  the 
shock,  and  men  learn  by  experience  where  to  stand  so  as  to  feel 
the  concussion  least." 

In  one  of  the  artillery  now  quartered  in  Dublin,  who  suffered 
from  haemorrhage  from  the  ears  the  first  time  he  was  at  field  prac- 
tice, fifteen  years  ago,  and  whose  ears  I  examined  this  day,  I 
found  a  small,  white,  well-defined  line  or  cicatrix  proceeding  from 
above  downwards  behind  the  manubrium  of  the  malleus,  than 
which  it  is  a  little  shorter.  Both  ears  presented  precisely  the  same 
condition,  and  the  haemorrhage,  he  says,  was  equal  upon  each  side. 
The  rest  of  the  membrane  is  normal ;  he  is  not  deaf 

A  medical  practitioner  at  Portsmouth  has  kindly  afforded  me 
the  following  note  of  his  own  case : — "  I  was  standing  about  half 
a  dozen  yards  from  a  large  cannon  when  it  was  fired  for  a  salute. 
At  the  instant  the  gun  was  fired  I  felt  a  very  severe  shock,  but 
unattended  with  pain,  in  my  right  ear,  whicii  was  that  nearest  the 
cannon.  I  immediately  perceived  that  I  had  lost  all  power  over 
the  right  side  of  my  face.  In  fact,  I  had  suddenly  become  affected 
with  *  Bell's  paralysis.'  At  the  end  of  ten  days,  finding  I  did  not 
recover,  I  applied  a  blister  to  the  back  of  my  neck,  lived  sparingly, 


and  took  a  sufficient  quantity  of  calomel  to  afTect  my  gums  slightly. 
Not  deriving  the  benefit  I  anticipated,  I  went  to  London  and 
consulted  Sir  B.  Brodie,  who  recommended  me  to  discontinue  all 
treatment  and  to  live  generously ;  when  I  soon  got  quite  well." 

I  was  consulted  by  Captain  H.  some  years  ago,  on  account  of 
total  deafness  of  the  right  car,  attended  with  an  incessant  buzzing 
noiae.  He  stated  that  he  lost  his  hearing  instantaneously  while 
grouse-shooting.  His  gun  had  been  overcharged,  and  '*  kicked** 
80  violently  as  to  cause  him  to  stagger;  he  felt  a  sharp  pain  in 
his  ear,  and  became  conscious  of  his  loss  of  hearing  immediately. 
The  membrana  tympani  was  very  much  collapsed. 

I  believe  that  the  best  treatment  which  can  be  adopted  for  re- 
cent injuries  of  the  membrana  tympani  is  to  let  them  alone,  unless 
inflammation  should  arise,  when  it  must  be  met  by  local  depletion, 
&c.  It  is  remarkable  that,  while  we  experience  the  greatest  diffi- 
culty in  keeping  open  a  perforation  made  with  a  surgical  instru- 
ment, accidental  openings  seldom  close. 


Myringitis,  or  inflammation  of  the  membrana  tympani,  has  not 
been  recognised  or  described  by  authors  until  within  the  last  few 
years:  and  its  varieties,  with  their  peculiar  symptoms,  are  by  no 
means  accurately  understood.  Itard,  one  of'tlie  earliest  and  most 
esteemed  writers  upon  aural  surgery,  has  not  mentioned  it,  though 
the  symptoms  of  at  least  one  form  of  the  disease  are  enumerated 
by  him  under  the  head  of  internal  otitis.  The  old  divisions  of 
inflammations  of  the  ear  into  otitis  externa  and  interna  do  not 
in  any  way  assist  either  our  diagnosis  or  improve  our  treatment, 
and  the  same  maybe  said  of  the  divisions  into  acute  and  chronic. 
The  otorrhoea  which  follows  in  such  cases,  and  which  formed, 
with  many  writers,  grounds  for  nosological  arrangement,  being  but 
a  symptom,  like  that  of  leucorrhoea  in  the  female,  is  an  insufficient 
ground  of  diagnosis. 

Lincke,  as  already  shown  at  page  144,  classes  the  aural  inflam- 
mations according  to  their  causes,  as  the  erysipelatous,  scrofulous, 
syphilitic,  &c. ;  but  the  exact  locality  or  seat  of  the  original  in- 
flammation, or  the  peculiar  appearance  of  such,  are  not  specified. 


These  are  merely  enumerations  of  diseased  actions,  generally  cha- 
racterized by  muco-purulent  discharge,  attendant  on,  or  following 
these  different  affections.  He  was,  however,  one  of  the  first  ac- 
curate describers  of  the  *^  JEntzundung  des  Trommel/ells^^'  the  true 

Kramer,  in  his  first  work,  gave  a  section  on  acute  inflamma- 
tion of  the  membrana  tympani,  but  upon  a  careful  perusal  of  it 
we  find  about  four  pages  devoted  to  the  description  of  that  clis- 
ease,  while  the  remainder  is  occupied  with  the  consideration  of 
polypus,  and  a  detail  of  the  various  methods  recommended  for 
performing  perforation. 

Mr.  Pilcher  disposes  of  inflammation  of  the  membrana  tym- 
pani in  a  few  pages,  but  enumerates  most  of  the  symptoms  of 
the  affection  (except  the  minute  appearances  of  the  membrane), 
under  the  head  of  otitis  interna.  Mr.  T.  W.  Jones  has  given  a 
short  description  of  one  form  of  the  disease.  I  cannot,  however, 
agree  with  him,  that  in  '*  otitis  interna  morbid  changes  in  the  mem- 
brana tympani  occur  only  when  it  is  threatened  with  bursting  by 
the  matter  accumulated  in  the  cavity  of  the  tympanum,  and  has 
also  become  involved  in  the  inflammatory  action."^  On  the  con- 
trary, my  experience  leads  me  to  believe  that  inflammation  of  the 
middle  ear  always,  and  at  the  very  commencement,  is  shown  by 
the  appearance  of  the  membrana  tympani ;  and  this  observation 
must  remain  undisputed  until  a  sufficient  number  of  accurate 
examinations  shall  have  been  made,  in  the  commencement  of 
cases  of  otitis  interna,  to  negative  it.  It  is  quite  plain  from  Dr. 
Williams's  account  of  the  **  inflammation  and  ulceration  of  this 
membrane,"*  that  he  never  examined  the  membrane  in  this  con- 
dition ;  indeed,  I  doubt  if  he  ever  saw  the  disease  under  consi- 

Dr.  Martell  Frank  has  given  a  concise  but  faithful  descrip- 
tion of  both  the  acute  and  chronic  form  of  the  disease.  M.  Hu- 
bert-Valleroux  does  not  even  enumerate  the  inflammation  of 
the  membrana  tympani  in  his  catalogue  of  aural  diseases;  and 
Schmalz  has  done  little  more  than  glance  at  the  disease.    He  has 

•  From  myringa — myrinx, — the  membrane  of  the  Uruin. 


evidently  mixed  up  the  description  of  its  symptoms  with  those  of 
other  inflammatory  affections  of  the  ear. 

In  the  following  cases  and  description,  the  inflammations  of 
the  membrana  tympani  have,  in  many  instances,  been  connected 
with  those  of  the  middle  ear,  because  I  do  not  believe  it  possible 
for  one  to  exist  independent  of  the  other  for  any  length  of  time : 
no  more  than  an  ophthalmia  can  be  circumscribed,  or  than  we  can 
by  the  term  iritis  define  a  simple  uncomplicated  inflammation  of 
the  membranous  diaphragm  of  the  ocular  chamber. 

By  the  term  myringitis  the  reader  is  to  understand  inflamma- 
tion of  the  membrana  tympani ;  and  by  tympanitis^  inflammation 
of  the  cavity  of  the  tympanum. 

Abscess  in  the  membrana  tympani  must  be  a  very  rare  disease. 
In  the  year  1843  I  had  opportunities  of  seeing  two  cases  of  a  cir- 
cumscribed deposit  of  pus  between  the  layers  of  the  membrane ; 
each  was  about  the  size  of  No.  6  shot ;  and  in  one  instance,  when 
I  punctured  the  abscess  with  a  cataract  needle,  a  small  drop  of 
pus  oozed  out. 

I  have,  in  the  nosological  chart  at  page  148,  enumerated  the 
various  inflammations  to  which  the  membrana  tympani  is  liable, 
but  for  all  practical  purposes  the  following  forms,  with  which  I  am 
myself  familiar,  will  suffice : — 

1.  Acute  inflammation  of  the  membrana  tympani,  commencing 
in  the  fibrous  layer,  accompanied  by  inflammation  of  the  cavity 
of  the  tympanum;  frequently  of  a  rheumatic  character.* 

2.  Sub-acute  inflammation,  unaccompanied  by  pain. 

3.  Syphilitic  inflammation. 

4.  Strumous  inflammation,  generally  in  the  mucous  layer,  with 
mucous  engorgement  of  the  tympanum. 

*  This  enuroeratioD,  bot  somowhat  differently  arranged,  is  that  which  I  adopted  in 
my  Essay  npon  *^  Inflammatory  Affections  of  the  Membrana  Tympani  and  Middle  Ear," 
pnblished  in  1848,  and  I  have  not  since  seen  reason  to  alter  it  or  render  it  more  minute. 
In  Mr.  Harvey*8  book  upon  "  Rheumatism,  Gout,  and  Neuralgia,"  &&,  of  the  Ear,  he 
states,  in  the  opening  paragraph,  that,  *'  Rheumatism  affecting  the  structures  of  the  ear 
has  not  hitherto,  as  far  as  my  researches  have  enabled  me  to  ascertain  the  fact,  been  noticed 
in  amy  medical  work."  Now,  both  Lincke  and  Frank  have  given  descrii)tions  of  gouty  and 
rheumatic  otitis ;  and  Mr.  Har\'oy  has  quoted  at  length  a  well-marked  instance  of  **  se- 
vere rheumatic  inflammation  of  the  membrane  and  cavity  of  the  tympanum,"  from  wy 
Essay  already  alluded  to. 



5.  Chronic  inflammation,  with  or  without  inflammation  of  the 
cavity  of  the  tympanum. 

6.  Febrile  inflammations,  accompanying  the  exanthcmatic  and 
other  fevers,  extending  from  the  tympanum,  and  generally  pro- 
ducing otorrhosa. 


In  actde  inflammation  of  the  membrana  tympanic  the  vascula- 
rity is  generally  seated  in  the  true  fibrous  structure,  and  is  usually 
the  result  of  cold,  and  often  attributed  to  rheumatic  diathesis, 
sudden  exposure  to  a  low  temperature,  blasts  of  harsh  cold  wind, 
diving  in  the  sea,  foreign  bodies,  and  irritating  substances  intro- 
duced into  the  external  car,  &c.  The  auditory  canal,  and  some- 
times even  the  auricle,  is  engaged ;  and  although  we  are  not  able 
to  observe  the  precise  pathological  condition  of  the  cavity  of  the 
middle  ear,  or  its  investing  membrane,  there  can  be  little  doubt 
but  these  parts,  sooner  or  later,  participate  in  the  general  inflam- 
matory action.  As,  however,  we  denominate  that  form  of  internal 
ophthalmia  which  chiefly  or  primarily  attacks  the  iris,  an  iritis, 
although,  in  the  severer  kinds  of  that  affection,  several  if  not  all, 
the  other  textures  of  the  eye  eventually  become  engaged,  so  in  in- 
flammations of  the  membrana  tympani,  to  which  the  term  my- 
ringitis is  applicable,  we  must  expect  that  sooner  or  later  the 
adjoining  structures, — the  mucous  membrane  lining  the  tympa- 
num, with  its  numerous  nerves,  the  nerves  which  cross  this  ca- 
vity, the  periosteum,  the  mastoid  cells,  the  investitures  of  the  Eus- 
tachian tube,  the  membrane  of  the  fenestra  cochlese,  the  muscles, 
ligaments,  and  other  connexions  of  the  ossicula,  the  labyrinth,  the 
internal  ear,  and  the  auditory  nerve  itself, — will  sooner  or  later 
participate  in  the  unhealthy  action  going  forward;  and  which 
must,  either  directly  by  the  inflammatory  lesion,  or  its  subsequent 
effects,  serve  to  impair  hearing,  and  cause  organic  changes  in  this 
delicate  organ.  But  in  addition  to  the  alterations  analogous  to 
those  which  occur  in  ophthalmic  inflammations,  we  may  have, 
from  the  peculiar  anatomical  structure  of  the  ear,  an  extension  of 
disease  to  parts  which  not  only  destroy  the  sense  of  hearing,  but 
prove  dangerous  to  life,  as  when  the  bone,  the  membranes  of  the 
brain,  or  the  enccphalon  itself,  become  engaged. 


The  dermal  structure  partakes  of  the  abnormal  action,  and,  to- 
gether with  that  of  the  auditory  canal,  pours  out  a  muco-purulent 
■ecretion,  or  even  pus  itself, — is  occasionally  raised  into  vesicles, 
becomes  the  seat  of  pustules,  ulcerates,  throws  out  granulations, 
and  becomes  thickened,  <S5C.,  during  the  progress  of  disease.  The 
true  fibrous  membrane  passes  through  all  the  pathological  changes 
to  which  such  structures  are  liable  from  inflammatory  action  or  its 
refolts;  and  although  the  precise  anatomical  condition  of  the  two 
may  not  be  analogous,. yet  the  diseases  of  the  cornea  and  of  the 
membrana  tympani  bear  a  remarkable  analogy,  particularly  in  the 
subsequent  appearances  of  vascularity,  thickening,  opacity,  and 
morbid  deposits,  &c.,  which  they  present,  together  with  adhesions 
by  bands  of  membrane  to  the  parts  within  the  chambers,  to  which 
they  form  the  external  boundaries. 

The  following  are  generally  the  order  of  symptoms.  A  seizure 
of  sudden  and  intense  pain  in  the  ear  itself,  most  generally  first 
appearing  at  night,  and  attended  with  nocturnal  exacerbations 
during  the  progress  of  the  disease.  This  pain  is  of  a  most  excru- 
ciating kind,  producing  at  times  delirium,  and  is  usually  likened 
to  that  of  a  sharp  instrument  penetrating  through  the  ear  to  the 
bndn:  it  is,  especially  when  the  cavity  of  the  tympanum  is  en- 
gaged, increased  by  coughing,  sneezing,  blowing  the  nose,  chew- 
ing, or  swallowing,  or  by  pressing  upon  the  tragus,  particularly 
when  the  jaw  is  open.  The  beating  of  the  carotid  is  distinctly 
felt  in  the  ear,  and  each  throb  of  the  artery,  especially  if  the 
circulation  be  excited,  increases  the  suffering;  and  there  is  fre- 
quently a  feeling  of  fulness  and  bursting  within  the  organ.  With 
this  there  is  also  pain  and  soreness  over  the  side  of  the  head,  in 
the  teeth,  in  the  eye  and  temple,  and  in  the  superior  lateral  tri- 
angle of  the  neck ;  with  occasionally  stiffness  and  soreness  of  the 
upper  portion  of  the  mastoid  muscle,  and  often  flying  rheumatic 
pains  throughout  the  body,  particularly  in  middle-aged  persons, 
and  those  who  have  previously  suffered  from  rheumatic  attacks. 
If  neglected,  or  unrelieved  by  treatment,  the  pain  extends  to  the 
throat  and  mastoid  region,  and  is  increased  on  pressing  the  mouth 
of  the  Eustachian  tube  with  the  finger.  The  severity  of  the  pain 
experienced,  and  the  extent  of  soreness  to  the  touch,  is  to  a  cer- 



tun  degree  a  test  of  the  amount  of  the  inflammation ;  and  the  pe- 
culiarity of  the  pain  is  also  a  means  of  judging  of  the  seat  of  the  in- 
flammation ;  for  if  it  is  experienced  in  swallowing,  mastication, 
or  sneezing,  <Sx;.,  we  may  presume  that  the  inflammation  has  ex- 
tended over  the  middle  ear. 

I  have  known  a  man  to  be  treated  for  inflammation  of  the  brain 
who  merely  laboured  under  inflammation  of  the  ear ;  and  on  the 
other  hand  a  very  curious  impression  exists  among,  and  is  too  fre- 
quently acted  on  by,  the  profession,  that. ear-ache  is  a  neuralgic 
afiection.  To  this  very  general  mistake  must  we  attribute  the 
practice,  so  frequently  and  empirically  resorted  to,  of  pouring  into 
the  ear  the  various  nostrums — sedatives,  and  stimulants,  calculated 
to  allay  pain  in  external  parts.  So  rare  is  true  neuralgia  of  the 
ear,  that  Dr.  Kramer  says,  he  **  never  observed  ear-ache  without 
evidence  of  inflammation  either  of  the  meatus  or  of  the  membrana 
tympani."  Although  I  am  not  prepared  to  go  the  length  of  saying 
that  such  an  afiection  does  not  occasionally  exist,  I  must  say  that 
I  cannot  tax  my  memory  with  more  than  one  or  two  instances  of 
so-called  **  nervous  otalgia,*^  for  which  I  have  been  consulted,  that 
upon  a  careful  examination  I  could  not  discover  some  direct  visi' 
bU  cause  for  it:  and  I  must,  therefore,  with  Dr.  Kramer,  "deny 
to  those  persons  the  right  of  pronouncing  a  decisive  opinion  on 
the  existence  of  a  nervous  otalgia,  who  do  not  understand  inves- 
tigating the  membrana  tympani  in  bright  sunshine,  and  with  the 
aid  of  the  speculum,  and  who  are  not  in  the  habit  of  doing  it."* 

Usually  coincident  with  the  seizure  of  pain,  the  patient  com- 
plains of  tinnitus  autium,  and  the  noises  are  described  as  a  dull 
throbbing,  or  pulsation, — a  loud  pumping  like  that  of  a  steam- 
engine, — with  the  occasional  supervention  of  a  sound  varying  in 
loudness  and  intensity  from  the  ticking  of  a  watch  to  the  striking 
of  a  loud  clock  ;  but  the  most  usual  simile  given  by  patients  in 
describing  those  ear-noises  is  that  tidal  sound  perceived  on  hold- 
ing a  conch-shell  to  the  ear.  In  the  severer  forms  of  aural  inflam- 
mation, patients  very  frequently  liken  this  unpleasant  symptom  to 
the  falling  of  water,  the  dashing  of  a  cataract,  or  that  peculiar 
rushing  sound  produced  by  the  sudden  escape  of  water  through 
a  large  pipe  or  sluice-gate.     In  the  more  mitigated  forms,  and  the 


more  advanced  and  chronic  stages,  we  generally  find  the  sounds 
of  a  hissing  or  blowing  character,  and  usually  likened  to  the  sing- 
ing of  a  kettle,  the  noise  of  a  distant  storm,  the  fluttering  of  the 
leaves  of  trees,  the  chirping  of  birds,  the  distant  ringing  of  bells,  a 
didl  cooing  in  the  ear,  musical  sounds  of  various  kinds,  the  buzz- 
ing of  bees,  blowing  of  bellows,  whistling,  and  other  noises  of  a 
similar  character,  to  which  I  have  already  referred  at  page  82. 
Any  increase  of  the  circulation,  or  nervous  excitement  of  any  kind, 
particularly  in  irritable  patients,  invariably  makes  these  ear-noises 

Deafness — consisting  either  of  impaired  hearing  or  total  loss 
of  that  sense  on  the  affected  side — comes  on  contemporaneously 
with  the  pain,  or  succeeds  it  in  a  few  hours  after ;  if,  however,  but 
one  side  has  been  attacked,  the  patient  is  not  at  first  conscious  of 
his  loss  of  hearing.  In  some  rare  cases  there  is  for  a  short  time 
daring  the  progress  of  tympanal  inflammation  an  exaltation  of  the 
sense  of  hearing,  in  which  (like  photophobia  in  ophthalmia)  all 
sounds  become  intolerable. 

In  severe  inflammations  of  the  ear,  pain  in  the  teeth  of  the 
affected  side  is  no  uncommon  accompaniment;  and  pain  from 
toothache,  with  or  without  decay  in  the  last  molar,  is  often  re- 
ferred to  the  ear.  We  should,  therefore,  carefully  distinguish  be- 
tween these  two  causes.  I  think  dentists  too  frequently,  and  with- 
out examining  the  state  of  the  meatus,  tell  patients  labouring 
under  ear-ache  to  *^  wait  until  the  teeth  are  set  right.**  In  cases 
of  chronic  ear-ache,  the  state  of  the  last  molar  tooth  should  always 
be  examined. 

To  these  local  subjective  symptoms  may  be  added  the  following 
constitutional  ones :  coryza,  sneezing,  coughing,  and  other  symp- 
toms of  catarrh,  increased  heat  of  skin,  headach  with  a  feeling  of 
weight  in  the  head,  and  sometimes  well-marked  hemicrania ;  there 
is  always  great  distress  and  anxiety  of  countenance ;  sleeplessness, 
restlessness ;  nocturnal  exacerbations,  the  acute  pain  coming  on  at 
a  particular  hour ;  quickness  of  pulse,  occasionally  rigors,  in  some 
instances  delirium,  and  even,  in  very  bad  cases,  all  the  symptoms 
of  cerebral  disease,  of  which  the  case  at  page  238  is  an  example. 
The  digestive  organs  are  seldom  much  engaged  in  the  progress 


of  the  disease ;  the  urine  becomes  high-coloured,  and,  towards  the 
termination  of  the  acute  symptoms,  deposits  a  copious  pinkish  sedi- 
ment. The  circulation,  except  in  very  severe  cases,  is  seldom 
much  affected. 

The  physical  signs  consist,  in  the  severe  cases,  of  heat,  pain, 
and  slight  erysipelatous  redness  of  the  auricle :  in  very  aggravated 
cases, — heat,  fulness,  and  oBdema,  as  well  as  pain  over  the  mastoid 
region,  and  great  soreness  of  the  scalp  on  the  affected  side.  In 
ordinary  cases  there  is  slight  tumefaction  of  the  lining  of  the  ex- 
ternal meatus;  complete  cessation  of  the  cerumenous  secretion;  a 
bright  pinkish  colour ;  a  swelling  and  polish  of  the  lining  of  the 
auditory  canal,  which  is  streaked  with  long  tortuous  vessels,  ac- 
companied by  heat  and  itching  of  that  part,  and  all  the  symp* 
toms  of  inflammation  described  at  page  194.  The  membrana 
tympani  first  loses  its  polish,  then  its  semi-transparency, — becomes 
in  the  early  stages,  and  in  very  mild  cases,  of  a  dull  yellow,  but 
this  is  variable  and  seldom  seen;  the  most  usual  colour  varies 
through  all  the  shades  of  red,  from  a  slight  pinkish  hue  to  that  of 
a  dark  damask  rose  tint,  and  is  caused  by  the  different  degrees  of 
vascularity  produced  by  the  greater  or  less  intensity  of  the  inflam* 
mation,  the  structures  engaged,  and  the  medium  through  which 
we  see  the  vessels.  In  addition  to  the  vascular  arrangement 
figured  and  described  at  page  216,  new  vessels  seem  during 
inflammatory  action,  like  as  in  the  coats  of  the  eye,  to  start  into 
existence,  and  to  branch  and  inosculate  till  the  whole  seems  one 
mass  of  bright  livid  red.  Generally  speaking,  the  upper  portion 
around  the  attachment  of  the  head  of  the  malleus  is  the  first  to 
become  vascular,  the  last  to  regain  the  natural  hue,  and  the  part 
in  which  the  colour  becomes  deepest.  The  vessels  alongside  the 
handle  of  that  bone  are  always  well  marked,  though  the  line  of  its 
attachment  remains  for  some  time  whitish,  owing  to  the  intimate 
connexion  of  the  membrane  to  it  at  this  part.  Around  the  cir- 
cumferential ligamentous  ring,  particularly  at  its  lower  and  an- 
terior part,  an  areola  of  short  vessels  form  a  crescent  of  almost 
a  line  in  breadth ;  they  all  run  towards  the  centre,  and,  when 
well  marked,  look  like  the  zone  seen  in  iritis,  or  that  observed 
in  the  edge  of  the  cornea  in  the  commencement  of  corneitis,  to 


which  difleaae  the  appearances  seen  in  myringitis  bear  a  great 
resemblance.  It  is  only  in  the  early  stage,  or  when  the  redness 
is  disappearing,  that  this  peculiar  peripheral  vascularity  is  well 
marked.  With  this  general  redness  may,  in  some  cases,  be 
seen  well-defined  patches  of  ecchymosis,  generally  on  the  anterior 
vibrating  portion ;  but  as  the  vascularity  increases,  even  the  exact 
position  of  the  manubrium  cannot  be  recognised, — all  is  one  red 
mass.  The  membrane  also  becomes  swollen,  and  its  surface  ap- 
parently villous  ;  rarely  vesicles,  and  still  more  rarely  pustules,  form 
on  its  surface.  Ulcers  occasionally  form  upon  it;  these  usually 
occupy  the  anterior  part  of  the  lower  vibrating  portion,  but  I 
have  occasionally  seen  them  situated  posteriorly.  It  is  possible 
that  they  may  have  commenced  as  vesicles  or  pustules,  but  we 
require  more  extended  and  minute  observations  to  determine  this 

Exudation  of  lymph  and  muco-purulent  secretion,  with  de- 
tachment  of  the  cuticle,  both  from  the  surface  of  the  membrane 
and  the  parietes  of  the  canal,  follow.  Lymph  is  very  frequently  ef- 
fiised  in  the  substance  or  between  the  laminse  of  its  proper  fibrous 
tonic,  and  there  can  be  little  doubt  that,  in  the  severe  forms  of  the 
disease,  this  morbid  product  is  poured  out  in  large  quantity  upon 
die  surface  of  the  tympanum,  the  membrane  of  which  must  par- 
take largely  of  the  inflammatory  action  so  visible  in  the  external 
septum.  That  these  lymphy  exudations — both  by  thickening 
the  tympanal  membrane  itself,  and  by  acting  in  a  similar  manner 
upon  the  lining  of  the  cavity  of  the  tympanum  and  the  parts 
contained  within  it,  by  bands  of  adhesion  within  its  walls,  thus 
drawing  inward  and  arresting  the  vibrations  of  the  membrana 
tympani,  curtailing  the  motion  of  the  ossicula,  injuriously  affect- 
ing the  membrane  of  the  fenestra,  and  particularly  by  impairing 
the  functions  of  those  tympanic  branches  of  the  glosso-pharyngeal 
nerve  which  ramify  on  the  mucous  membrane — are  the  principal 
causes  of  deafness,  I  have  little  doubt.  Perforation  of  the  tym- 
panal membrane,  either  by  rupture,  abscess,  slough,  or  ulceration ; 
but  which  it  is  not  always  easy  to  determine,  also  occurs  occasion- 
ally. When  rupture  takes  place,  and  that  accumulations  of  bloody 
mucus,  or  purulent  matter,  pent  up  within  the  tympanum,  are 


evacuated,  relief  is  generally  experienced.  In  this  condition — with 
the  cavity  of  the  tympanum  open,  polypoid  growths  occurring  in 
the  meatus,  and  granulating  over  the  surface  of  the  tympanum, 
and  a  copious  and  very  often  fetid  discharge  pouring  both  from 
the  auditory  passage  and  the  drum — the  case  becomes  one  of  otor- 
rhoea,  the  peculiar  symptoms  and  management  of  which  are  de- 
tailed in  the  chapter  on  that  subject. 

In  cases  where  neither  rupture  nor  ulceration  has  taken  place, 
as  the  disease  advances,  the  vascularity  of  the  membrana  tympani 
decreases,  first  in  the  centre  of  its  vibrating  portion,  then  around 
its  circumference,  and  finally  along  the  mallear  attachment.  The 
membrane  assumes  a  muddy,  yellowish,  opaque  colour;  after  this 
clears  off  we  find  it  opaque  throughout,  or  in  spots ;  sometimes 
these  opacities  can  be  plainly  discovered  upon  the  interior  of  the 
membrane,  like  the  speckled  opacities  seen  upon  the  membrane 
of  the  aqueous  humour.  In  other  cases,  the  result  of  the  inflam- 
mation is  seen  in  the  uniform  greyish-white  opacity,  similar  to 
leucoma  of  the  cornea ;  and  in  time,  as  the  superficial  polish  is  re- 
stored, the  membrane  presents  a  pearly  aspect  very  different  from 
the  semi-transparent  character  of  the  healthy  condition. 

A  not  uncoinmon  effect  of  inflammation  of  the  tympanum  and 
its  membranes,  particularly  when  allowed  to  run  its  course  un- 
checked, is  collapse  on  a  drawing  inward  of  the  membrana  tym- 
pani, as  explained  at  page  138.  In  such  cases  the  handle  of  the 
hammer  forms  the  most  projecting  point  seen  at  the  bottom  of  the 
auditory  canal ;  and  the  anterior  and  posterior  divisions  of  the 
membrane  can  be  distinctly  observed  forming  deeply  curved  folds 
upon  either  side  of  it. 

The  inflammatory  process  must,  in  severe  cases,  also  extend 
into  the  mastoid  cells ;  the  periosteum  lining  the  bony  portion  of 
the  auditory  canal  will  in  time  become  engaged,  as  well  as  the 
pericranium  over  the  mastoid  process,  and  post-aural  region  of  the 
skull,  and  present  the  symptoms  already  described.  If  allowed 
to  proceed  unchecked,  by  the  efforts  of  nature  or  by  art,  the 
death  of  the  bone  beneath  will  follow ;  while,  in  cases  still  more 
severe,  the  entire  petrous  portion  of  the  temporal  bone  will  be- 
come inflamed, — the  dura  mater  will  separate  from  it, — purulent 


deposit  takes  place  in  the  cavity  thus  produced, — the  brain,  as 
well  as  its  investments  opposite  those  portions,  will  partake  of  the 
inflammation, — and  death  follow,  either  from  abscess,  or  diffuse 
inflammation  of  the  cerebrum  or  cerebellum. 

In  some  rare  cases,  paralysis  of  the  muscles  of  the  face,  on  the 
afiected  side,  presenting  all  the  peculiar  phenomena  of  that  disease, 
is  produced ;  instances  of  which  will  be  related  hereafter. 

During  the  progress  of  the  inflammatory  action  in  the  tympa- 
num and  its  external  membrane,  the  throat,  in  some  cases,  becomes 
engaged,  its  mucous  membrane  presenting  a  copperish-red  appear- 
ance, and  becoming  swollen  and  infiltrated.  The  tonsils  are 
also  swollen ;  there  is  some  difficulty  of  deglutition ;  and  if  an 
examination  of  the  pharyngeal  extremity  of  the  Eustachian  tube 
be  made  with  the  finger,  according  to  the  method  described  at 
page  80,  considerable  pain  is  experienced  in  the  track  of  the  tube, 
as  well  as  in  the  middle  ear.  There  can  be  little  doubt  of  the 
inflammatory  condition  of  the  middle  ear,  extending  over  the 
Eustachian  tube,  and  causing  such  thickening  and  obstruction  of 
its  lining  membrane,  with,  perhaps,  an  accumulation  of  mucus,  as 
greatly  impedes  the  transit  of  air  into  the  drum,  and  causes  that 
peculiar  feeling  of  stuffing,  and  occasional  sudden  bursting  in  the 
middle  ear,  of  which  we  are  all  conscious  when  labouring  under 
influenza  or  catarrh. 

The  nose  sometimes  partakes  in  the  unhealthy  condition  of 
the  neighbouring  mucous  membrane,  and  a  feeling  of  stuffing 
in  that  part,  together  with  much  faucial  respiration,  is  not  an  un- 
common attendant  upon  acute  inflammation  of  the  middle  ear  and 
membrana  tympani. 

This  form  of  inflammation  chiefly  attacks  the  young  and  mid- 
dle-aged ;  one  ear  is  much  more  frequently  affected  than  both ;  the 
light-haired  and  fair-complcxioned  are  more  liable  to  it  than  the 
dark.  So  much  more  frequent  are  its  attacks  in  spring  than  at 
any  other  period  of  the  year,  that  it  sometimes  seems  to  be  epide- 
mic at  that  time.  The  duration  of  the  disease  varies  from  six  to 
fourteen  days,  but  may  last  a  month,  and  its  efifects  several  months. 

In  the  foregoing  description  it  was  impossible  to  avoid  details 
and  symptoms  common  to  inflammation  of  the  cavitas  tympani — 


true  otitis — and  its  membranous  partition,  because  the  diseased 
action  sooner  or  later  extends  from  the  one  to  the  other. 

With  respect  to  treatment,  the  temperature  in  cases  of  acute 
myringitis  should  be  strictly  attended  to :  the  patient  should,  if 
possible,  be  confined  to  a  warm,  well-ventilated  apartment,  or,  if 
obliged  to  go  abroad,  the  cold  air  should  be  carefully  excluded 
from  the  ear ;  but  in  the  severe  form  of  the  disease  it  is  absolutely 
necessary  to  confine  the  patient  to  bed. 

I  have  never  had  occasion  to  employ  general  bleeding ;  but 
local  depletion,  either  by  means  of  cupping  or  leeches,  is  invari- 
ably necessary ;  and  leeches  are  not  only  the  most  effectual  and 
easiest  mode  of  abstracting  blood,  but  they  can  be  applied  nearest 
the  seat  of  disease,  and  repeated  as  frequently  as  necessary.  To 
be  effective  they  must  be  applied  according  to  the  directions  which 
I  have  given  at  page  85,  to  which  I  would  here  particularly  direct 
the  attention  of  the  reader.  The  auditory  canal  having  been  filled 
with  cotton  wool,  to  prevent  them  going  in  too  far,*  and  the 
blood  from  flowing  into  it,  five  or  six  leeches  should  be  attached 
round  the  external  meatus,  the  direct  vascular  communication  of 
which  with  the  membrana  tympani  I  have  already  pointed  out 
at  page  217.  I  fallowed  to  scatter  over  the  concha,  they  will 
not  afford  the  same  amount  of  relief:  but  several  may  be  applied 
in  front  of  the  tragus,  and  others,  if  necessary,  close  into  the  an- 
gle between  the  auricle  and  the  mastoid  process.  The  bleeding 
should  be  encouraged  by  warm  applications,  stupes,  and  poultices, 
and,  if  necessary,  kept  up  by  relays  of  leeches  for  eight  or  twelve 
hours  together.  The  relief  afforded  by  leeches  in  this  disease  is 
often  instantaneous,  and  is  always  most  marked. 

The  employment  of  moist  heat,  as  directed  at  page  89,  will 

*  I  knew  one  instance  in  which,  from  the  omission  of  the  cotton,  a  leech  attached  itself 
somewhere  within  the  meatus,  and  caused 
the  most  excruciating  agony.  Although  I 
generally  mark  the  places  to  which  the 
leeches  should  be  attached  with  spots  of 
ink,  I  have  frequently  the  mortification  of 
finding  that  they  have  been  allowed  to  at- 
tach themselves  to  places  tax  remote  from  the  edge  of  the  meatus.  The  apothecary 
should  bring  with  him  a  laigc  quantity  of  leeches,  and  employ  the  glass  here  figured 
of  the  natural  size. 


alwajrs  afford  relief.  In  addition  I  may  mention,  that  applying 
the  tube  attached  to  a  Mudge's  inhaler  to  the  external  auditory 
paasagOy  and  allowing  the  warm  vapour  to  have  access  to  the  in- 
flamed parts,  will  give  the  patient  great  comfort. 

When  there  is  much  external  neuralgic  pain,  or  rheumatic 
soreness  and  tenderness  to  the  touch  about  the  external  ear,  and 
over  the  side  of  the  head  and  face,  relief  will  be  experienced  from 
the  various  sedative  applications,  of  which  I  may  mention  three, 
— ^tincture  of  aconite,  chloroform,  and  the  belladonna  with  com- 
pound camphor  liniment.  There  are  two  popular  remedies  for 
*'  a  pun  in  the  ear"*  still  in  very  general  use, — the  application  of 
a  roasted  fig,  and  the  insertion  into  the  meatus  of  a  hot  roast  onion 
or  a  clove  of  garlic.  The  former  is  innocuous,  the  latter  is  by  no 
means  harmless.  The  empirical  practice  of  pouring  laudanum  and 
oil  into  the  ear  the  moment  pain  is  complained  of,  employed  by 
the  profession,  is,  I  trust,  on  the  wane. 

The  bowels  should  in  this,  as  in  all  other  febrile  diseases,  be 
opened,  but  the  condition  of  the  digestive  organs  does  not  appear  to 
influence  the  inflammatory  affections  of  the  ear  as  much  as  they  do 
those  of  the  eye.  The  state  of  the  skin,  however,  which  is  gene- 
rally hot  and  dry,  requires  our  more  especial  attention ;  and  sudo- 
rifics  are,  in  the  early  stage  of  the  disease,  decidedly  indicated. 
Having  leeched,  fomented,  and  purged,  Jameses  powder,  combined 
with  small  doses  of  blue  pill  and  henbane,  will  be  found  very  effl- 
cacious.  Abstinence  from  animal  food,  and  the  use  of  the  foot- 
bath, together  with  all  such  means  as  arc  calculated  to  allay 
inflammation  and  febrile  excitement,  should  be  had  recourse  to. 

Counter-irritation,  by  means  of  small  blisters  applied  upon  the 
bald  space  behind  the  auricle,  and  below  the  lobe,  are  advanta- 
geous in  the  more  advanced  stage  of  the  disease,  and  after  local 
depletion  has  been  fully  employed.  Generally  speaking,  blisters 
are  too  much  relied  upon,  or  applied  too  early  in  the  disease ;  but 
as  it  advances  they  will  be  found  highly  useful. 

Having  resorted  to  all  those  means,  we  should,  if  the  symp- 
toms— ^not  only  of  pain  and  deafness,  but  of  the  redness  and  vas- 
cularity of  the  tympanal  membrane^ — remain  unrelieved,  at  onco 
have  recourse  to  the  use  of  mercury.     Indeed  I  am  now  so  fully 


convinced,  not  only  of  the  utility,  but  of  the  urgent  necessity  of  em- 
ploying mercury  in  these  aural  inflammations,  that  I  do  not  hesi- 
tate to  recommend  its  use  in  the  early  stages  of  all  such  affections. 
A  pneumonia,  a  pericarditis,  a  peritonitis,  an  inflammation  of  a 
large  joint  or  a  serous  cavity,  or  an  iritis,  may,  it  is  true,  get  well 
by  simple  depletion,  &c. ;  but  will  any  experienced  practitioner  of 
the  present  day  risk  such  a  case  without  having  recourse  to  mer- 
cury ?  For  the  reasons  applicable  in  these  instances, — from  the 
peculiar  effect  which  mercury  exercises,  not  only  in  most  inflam- 
mations, but  especially  over  those  of  flbrous  membranes ;  and  in 
order  to  arrest  the  exudation  of  lymph,  and  to  cause  the  absorp- 
tion of  those  effusions  which,  by  thickening  the  membrane,  and 
causing  those  pathological  effects  to  which  I  have  already  so  fre- 
quently alluded,  and  which  prove  so  constantly  the  cause  of  sub- 
sequent deafness ;  as  well  as  the  urgent  necessity  for  arresting  the 
progress  of  inflammation  in  a  part  that  may  prove  destructive  to 
life, — it  is,  that  I  so  strongly  advocate  the  employment  of  this  re- 
medy. I  find  that,  in  most  instances,  where  it  is  employed  early, 
it  produces,  as  soon  as  it  affects  the  system,  as  well-marked  an  im- 
provement in  all  the  symptoms  as  it  does  in  any  of  the  other  in- 
flammations which  I  have  enumerated.  It  should,  therefore,  be 
given  in  small,  frequently-repeated  doses ;  and  the  formula  I  find 
most  efficacious  is  calomel  and  blue  pill,  guarded  with  opium,  and, 
if  the  stomach  will  bear  it,  a  very  small  quantity  of  James's  pow- 
der. Not  only  should  the  gums  be  touched,  but  the  patient  should 
be  kept  under  its  gentle  influence  for  some  days,  in  order  to  insure 
an  ultimate  beneficial  result. 

In  the  subsequent  management  of  the  disease,  the  iodide  and 
bromide  of  potassium,  or  very  minute  doses  of  the  bichloride  of 
mercury  in  some  of  the  preparations  of  bark,  will  certainly  hasten 
the  cure,  as  well  as  promote  absorption  of  the  deposits  and  adhe- 
sions already  alluded  to.  The  tinnitus  which  remains  is  more 
likely  to  be  removed  in  time  than  that  attending  chronic  deafness. 

The  state  of  the  meatus  and  membrana  tympani  should  be  ex- 
amined with  a  speculum  daily,  or  oftener  if  necessary ;  and  then, 
should  we  discover  an  ulcer,  it  may  be  touched  with  a  solution  of 
nitrate  of  silver  applied  with  a  fine  camel's-hair  pencil.     If  otor- 


riiGM  has  occurred  either  in  the  form  of  muco-serous  exudation, 
from  the  external  surface  of  the  tympanal  membrane  and  the  au- 
ditory canal,  or  owing  to  pus  or  mucus  escaping  from  the  middle 
ear  through  an  aperture  in  the  membrana  tympani,  or  from  abscess 
in  the  walls  of  the  external  auditory  canal,  we  should  remove  the 
discharge  by  very  gently  syringing  the  part  with  simple  warm 
water,  or  the  most  bland,  unirritating  fluid ;  but  during  the  high 
inflammatory  process  no  astringent  injections  whatever  should  be 

If  polypoid  growths  of  any  magnitude  sprout  suddenly  from 
the  auditory  canal,  they  should  be  removed  with  the  snare,  or 
touched  with  the  solid  nitrate  of  silver;  and  this  latter,  if  properly 
done,  does  not  give  rise  to  any  fresh  attack  of  inflammation. 

Should  the  mastoid  process,  or  the  parts  covering  it,  become 
engaged,  and  that  the  methods  already  recommended  fail  to  give 
relief,  or  that  even  an  indistinct  sense  of  fluctuation  can  be  dis- 
covered, we  should  not  long  hesitate  to  make  a  free  incision  in 
the  periosteum  there,  at  least  an  inch  in  length.  In  performing 
this  operation,  the  head  should  be  firmly  secured,  and  supported 
against  some  unyielding  substance,  as  the  back  of  a  high  chair,  or 
the  breast  of  an  assistant.  A  stout  scalpel  is  the  best  instrument 
to  employ :  the  blade  should  be  grasped  by  the  fore-finger  and 
thumb,  so  as  to  leave  about  an  inch  of  it  uncovered ;  and  inserted 
steadily  till  the  point  reaches  the  bone,  which  it  should  be  made 
to  traverse  for  the  full  length  of  the  incision.  By  this  means  we 
secure  complete  division  of  the  periosteum.  With  regard  to  the 
line  of  the  incision,  circumstances  may  require  its  being  made  in 
other  directions,  but  I  find  that  it  is  most  generally  required  pa- 
rallel with,  and  about  three-quarters  of  an  inch  from,  the  attach- 
ment of  the  auricle,  in  order  to  avoid  the  posterior  aural  artery, 
which,  when  divided,  bleeds  profusely.  The  knife  should  be 
drawn  from  below  upwards;  and  from  the  swollen  state  of  the 
parts,  the  depth  which  we  are  sometimes  obliged  to  introduce  the 
instrument  is  often  nearly  an  inch.  The  hasmorrhage,  unless  we 
wish  to  extract  blood,  may  be  arrested  by  placing  a  dossil  of  lint 
within  the  incision.  The  cut  surfaces  generally  present  the 
brawn-like  appearance  seen  in  phlegmonoid  erysipelas.  Although 


pus  may  not  have  been  reached  by  the  incision,  still  immediate 
relief  is  almost  invariably  experienced.  The  subsequent  manage- 
ment of  this  particular  part  of  such  a  case  must  depend  upon  the 
circumstance  of  exfoliation,  &c. 

The  following  cases  exhibit  many  of  the  phenomena  detailed 
in  the  foregoing  description.  They  are  given  at  somewhat  greater 
length  than  would  be  necessary,  were  the  diseases  of  the  ear  as 
much  attended  to  by  the  general  physician  or  surgeon  as  they 
ought,  or  if  the  treatment  of  those  diseases  formed  a  part  of  the 
present  system  of  medical  education  in  these  countries. 

Acute  myringitis  and  tympanitis  in  both  ears,  with  severe 
head  symptoms ;  recovery  under  the  use  of  mercury. 

Master  J — ,  aged  twelve  years,  with  light  hair  and  florid  com- 
plexion (whose  elder  brother  had  been  under  my  care  a  short  time 
previously  for  chronic  inflammation  of  the  left,  and  acute  inflamma- 
tion of  the  right  ear),  had  always  enjoyed  good  health,  and  never 
had  any  aural  aflcction,  till  Sunday,  the  1st  of  August,  1847,  when 
he  was  attacked  with  slight  pain  in  the  right  ear.  Upon  the  Fri- 
day previous  he  had  bathed  in  the  open  sea  five  times,  and  had 
dived  frequently  each  time.  Upon  the  day  following  he  bathed 
three  times,  and  also  dived.  He  awoke  on  Sunday  morning  early, 
with  some  pain  in  the  right  ear,  but  made  no  complaint,  as  he 
says  it  was  but  slight;  it  was  accompanied,  however,  by  a  feeling 
of  pressure,  as  if  something  was  bursting  out  through  the  ear.  He 
bathed,  however,  again,  twice  upon  that  day.  Towards  evening 
pain  came  on  in  the  left  ear,  and  increased  greatly  in  the  right. 
He  retired  to  rest  early,  and  having  been  reminded  of  the  provo- 
cation for  his  pain,  he  made  no  further  complaint.  About  twelve 
o'clock  that  night,  however,  his  mother  was  awoke  by  his  cries 
and  moans,  the  result  of  the  extreme  agony  which  he  was  then 
suflfering.  A  neighbouring  practitioner  was  applied  to,  and  some 
camphorated  oil  and  laudanum  dropped  into  the  ear.  This  treat- 
ment, however,  afforded  him  no  relief,  and  he  remained  awake  all 
night,  moaning  much,  and  complaining  of  the  violent  pain  in  his 
head  and  ears,  which  he  likened  to  a  sharp  instrument  penetrating 
from  without. 

I  saw  him  on  Monday  morning,  the  2nd,  about  ten  o'clock; 


the  £tice  was  flushed,  and  the  countenance  anxious  and  expressive 
of  extreme  pain.  The  pupils  were  rather  more  contracted  than 
naturaly  and  the  eyes  slightly  sensitive  to  light;  he  had  some  heat 
of  skin,  but  the  pulse  was  not  above  76 ;  the  bowels  were  consti- 
pated, and  the  urine  natural.  The  auricle  and  external  meatus 
were  normal;  considerable  pain  was  experienced  upon  pressing 
the  cartilage  behind  the  articulation  of  the  jaw,  but  pressure  over 
the  mastoid  region  was  borne  with  impunity.  The  auditory  canal 
was  a  light  rose  colour,  quite  dry,  and  devoid  of  cerumen ;  the 
membrana  tympani  was  distinctly  seen,  with  a  deep  pink  colour 
generally  diflused  over  it,  but  increasing  in  intensity  in  a  cresccntic 
form  round  its  lower  insertion,  and  also  in  the  line  of  the  attach- 
ment of  the  malleus.  The  appearances  were  nearly  the  same  on 
both  sides.  As  this  boy  was  brought  to  my  house,  I  had  a  bettor 
opportunity  of  accurately  recording  the  state  of  the  parts  than  one 
is  usually  able  to  effect  in  the  sick  chamber.  The  appearance  of 
the  throat  was  normal ;  the  Gnger  pressed  against  the  mouth  of  the 
Eustachian  tube  caused  but  slight  increase  of  the  pain.  Air  passed 
up  with  difiiculty  into  the  tympanal  cavity  on  making  a  forced 
expiration.     Hearing  was  then  unimpaired. 

He  was  ordered  to  be  put  to  bed ;  to  take  a  purgative  bolus, 
and  to  have  two  leeches  immediately  applied  to  the  posterior  mar- 
gin of  the  external  meatus,  as  far  in  as  possible,  on  both  sides. 
The  leeches  afforded  some  relief,  but  towards  evening  the  pain 
returned  with  great  violence.  He  became  quite  delirious  about 
six  o'clock ;  did  not  know  his  friends ;  and  could  with  difficulty 
be  retained  in  bed.  I  saw  him  about  eight  o'clock ;  he  was  then 
in  high  fever,  but  more  sensible ;  there  was  great  heat  of  skin ; 
pulse  80,  and  fuller  than  in  the  morning;  tongue  clean;  bowels 
had  been  fully  opened ;  urine  free  and  limpid ;  no  thirst ;  knows 
all  his  friends  now,  but  does  not  pay  much  attention  to  what  is 
going  forward  about  him ;  is  quite  rational  when  spoken  to;  com- 
plains of  intolerance  of  light ;  face  has  become  more  flushed  and 
anxious ;  complains  now  of  the  great  weight  of  his  head,  which  he 
rolls  about  from  side  to  side ;  has  had  no  sleep.  On  examination  I 
found  that  the  redness  of  the  passage  and  membrane  of  the  drum 


had  greatly  increased  since  morning,  but  there  was  no  tumefaction 
of  either.  Pressure  or  percussion  of  the  mastoid  process,  and  the 
infra-aural  region,  was  borne  without  wincing.  Two  more  leeches 
were  ordered  to  be  applied  over  the  articulation  of  the  jaw,  in 
front  of  the  tragus  upon  each  side,  and  small  doses  of  calomel, 
opium,  and  James*s  powder  to  be  administered  every  third  hour. 
The  ear  to  be  steamed  over  hot  water,  and  a  linseed  poultice  to 
be  applied  subsequently.     Scarcely  any  diminution  of  hearing. 

3rd.  Has  passed  a  sleepless  night,  raving  occasionally.  All 
his  previous  symptoms  continue  unabated,  in  addition  to  which, 
he  now,  for  the  first  time,  complains  of  noise  in  his  ears,  which  he 
likens  to  that  of  the  tide,  and  which  is,  he  says,  generally  diffused 
through  the  head  as  well  as  in  the  ears.  The  pain  has  somewhat 
increased ;  he  says  he  feels  as  if  a  lance  was  running  into  his  head ; 
bowels  free.  Blisters  ordered  to  be  applied  behind  the  ears  upon 
both  sides.  During  the  night  of  Tuesday  he  again  became  vio- 
lent, and  did  not  know  his  friends.  The  urine  became  remarkably 
dark-coloured.  He  had  no  sleep.  The  mercury  was  steadily  per- 
severed in,  and  towards  morning  he  complained  of  some  soreness 
of  his  mouth  and  gums. 

4th.  He  passed  another  sleepless  night ;  raved  occasionally ; 
countenance  less  anxious;  pulse  not  so  full;  pain  in  ears  and  head 
very  much  less ;  mercurial  fetor ;  mouth  slightly  sore ;  complains 
of  pain  in  swallowing,  which  he  refers  to  the  middle  ear.  He  has 
become  very  deaf;  says  the  noise  has  increased,  and  is  now  of  two 
kinds, — a  continuous,  uninterrupted  bellows  sound,  and  an  occa- 
sional ticking,  like  that  of  a  loud  watch,  which  commences  and 
stops  suddenly ;  membrane  and  passage  unaltered.  Interval  be- 
tween doses  of  mercury  increased. 

5th.  He  is  much  better  in  every  respect;  has  had  no  delirium 
since  last  report ;  lies  quiet  on  his  side ;  he  is  remarkably  tranquil, 
and  has  had  some  sleep ;  the  light  is  still  offensive  to  him  ;  skin 
cooler ;  pulse  80 ;  bowels  free ;  mouth  very  sore ;  deafness  still 
continues ;  noise  in  head  not  so  violent ;  urine  high-coloured ;  the 
membrana  tympani  and  auditory  canal  are  much  less  red.  Mer- 
cury omitted ;  the  occipital  region  was  ordered  to  be  shaved,  and 


two  small  blisters  to  be  applied  behind  the  insertion  of  the  mas- 
toid muscles.  His  chief  complaint  now  is  of  the  soreness  of  his 
mouth  from  the  effects  of  the  mercury. 

6th.  At  eleven  o'clock  this  morning  he  was  suddenly  attacked 
with  acute  pain  in  both  ears,  of  a  sharp  lancinating  character. 
Leeches  were  again  applied  round  the  meatus  on  both  sides,  and 
warm  stupes  and  fomentations  also  had  recourse  to.  These  means 
afforded  him  relief  in  a  short  time. 

7th.  Has  slept  well  during  the  previous  night;  had  no  return 
of  the  acute  pain,  but  a  dull  aching  still  continues  in  both  cars ; 
he  is  very  deaf  to-day,  but  he  is  not  so  sensitive  to  light ;  the  bel- 
lows noise  still  continues  in  his  ears,  and  that  which  was  formerly 
described  as  the  ticking  of  a  watch,  he  now  likens  to  the  clapping 
of  two  pieces  of  iron  together.  He  only  hears  an  ordinary  ticking 
watch  when  it  is  pressed  against  the  auricle  of  the  left  side,  not  at 
all  on  the  right ;  he  does  not  hear  it  when  applied  to  the  forehead, 
or  held  between  the  teeth,  and  but  very  faintly  when  applied  upon 
the  mastoid  process.  He  complains  of  a  return  of  the  weight  in 
his  head  to«day ;  sleeps  much ;  bowels  free ;  urine  of  a  dark  brown 
colour,  and  depositing  a  pinkish  sediment ;  mouth  very  sore.  Upon 
the  visit  at  four  o'clock  in  the  evening  the  countenance  was  found 
more  tranquil  than  on  any  previous  occasion ;  the  skin  cool ;  pulse 
75 ;  functions  natural :  pressure  on  the  tragus  is  now  borne  with 
impunity.  Upon  inspection,  the  membrana  tympani  was  found 
much  less  red,  particularly  on  the  left  side ;  it  is  also  beginning  to 
dear  above  the  malleus ;  mouth  still  very  sore ;  ordered  a  gargle, 
and  to  have  light  broth. 

9th.  Much  better  in  every  respect.  A  slight  muco-purulent 
discharge  now  appears  from  the  meatus  of  the  right  ear.  On  re- 
moving this  with  a  little  tepid  water,  and  bringing  the  membrana 
tympani  within  the  6eld  of  the  speculum,  the  redness  was  found 
to  have  greatly  disappeared,  except  on  two  or  three  spots,  about 
the  size  of  pin-heads ;  all  the  intermediate  portions  of  the  mem- 
brane had  become  white,  and  apparently  thick  and  pulpy.  Upon 
the  leftside  a  slight  mucous  discharge  coats  over  the  surface  of  the 
membrane  of  the  drum,  and  the  inferior  portion  of  the  canal;  hav- 
ing removed  this  with  a  little  cotton  on  a  probe,  the  vascularity 



which  had  previously  appeared  on  those  parts  was  found  to  have 
greatly  diminished  ;  but  the  membrane  itself  had  become  thick- 
ened and  opaque.  He  is  quite  free  from  pain ;  the  hearing  dis- 
tance has  increased  to  about  two  inches  on  each  side.  On  the  right 
side  two  small  glands  have  now  appeared  beneath  the  lobe,  and 
another  slightly  enlarged  over  the  mastoid  process ;  ordered  three 
grains  of  the  hydriodate  of  potash  three  times  a  day,  and  nutri- 
tious diet. 

12th.  Has  very  much  improved  in  every  respect  since  last  report ; 
18  now  quite  free  from  fever,  but  very  weak  and  languid ;  tongue 
clean ;  soreness  of  mouth  quite  removed ;  pulse  60 ;  has  some  appe- 
lite ;  sat  up  for  a  short  time  yesterday ;  glands  in  the  neck  much  les- 
sened, that  over  the  mastoid  process  still  tender ;  is  quite  free  from 
pain  in  the  ears,  but  still  complains  of  a  slight,  generally  diffused 
pain  in  his  head  ;  there  is  no  intolerance  of  light ;  hearing  dis- 
tance has  increased  to  eighteen  inches  on  each  side ;  has  had  no 
discharge  from  either  ear ;  the  loud  ticking  noise  has  quite  disap- 
peared, but  the  buzzing  or  bellows  sound  is  still  slightly  percep- 
tible ;  any  surrounding  noise  is  particularly  distressing  to  him ;  he 
lays  he  feels  as  if  it  struck  his  ear.  Upon  examination  of  the 
right  ear,  the  passage  is  found  to  be  quite  dry,  and  of  a  light  pink 
colour ;  the  membrana  tympani  generally  is  somewhat  redder  than 
on  the  occasion  of  my  former  visit ;  and,  besides  this  generally 
diffused  redness,  there  is  a  deep-coloured  ring  of  vessels  to  be  seen, 
forming  a  crescentic  band  about  a  line  in  breadth,  occupying  the 
lower  portion  of  the  membrane,  the  vessels  of  which  can  be  dis- 
tinctly seen  running  in  nearly  straight  lines  from  the  circumfe- 
rence towards  the  centre.  The  projection  of  the  malleus  is  marked 
by  a  fasciculus  of  dark  red  vessels,  running  along  the  course  of  its 
attachment.  In  the  left  ear  the  general  redness  of  the  passage  and 
the  membrane  is  not  so  great,  and  there  is  no  ring  of  vessels  such 
as  exists  upon  the  right  side.  He  states  that,  on  blowing  his  nose, 
he  felt  as  if  something  gave  way  in  his  right  ear,  and  that  imme- 
diately his  hearing  increased,  and  on  repeating  the  experiment  a 
few  times,  the  same  phenomena  took  place  in  the  leil  ear.  Since 
then  his  hearing  has  gradually  improved  to  the  present  time ;  he 
was  ordered  to  be  blistered  again  behind  the  ears,  to  continue  the 


of  the  potasli,  to  sit  up  for  a  few  hours  every  day,  and  have 
nutritious  diet. 

16th.  Has  continued  to  improve ;  hearing  has  increased  to  three 
jfeet  upon  the  right,  and  four  feet  upon  the  left,  side.  The  right 
membrana  tympani  is  found  much  less  vascular  but  somewhat  more 
opaque  than  the  left,  which  is  still  of  a  uniform  pinkish  colour, 
but  has,  nevertheless,  regained  its  polish  and  scraitransparency 
much  more  than  the  other.  The  buzzing  noise  is  still  slightly 
fislt.  The  blisters  were  repeated,  and  the  potash,  with  tincture 
of  iodine,  continued;  slight  open  air  exercise  permitted. 

18th.  From  the  general  improvement  in  his  health,  he  was  en- 
abled to  visit  me  at  my  house  on  this  date.  He  states  that  the  buz- 
zing and  all  other  noises  have  completely  disappeared.  The  mem- 
brani  tympani  on  the  right  side  is  found  to  have  lost  much  of  its 
yascularity,  but  is  uniformly  opaque,  and  is  also  dull  upon  its  sur- 
&ce ;  with  this  ear  the  hearing  distance  is  now  four  feet,  whereas 
with  the  left,  which  is  still  very  vascular,  but  much  more  trans- 
parent, the  hearing  distance  is  now  full  six  feet.  A  generous  diet, 
and  the  potash  and  iodine  ordered  to  be  continued. 

Sept.  25th.  His  general  health  is  now  quite  restored ;  his  hear- 
ing as  good  as  ever ;  the  noise  has  entirely  disappeared.  During 
the  past  month  ablush  of  redness  has  several  times  appeared  upon 
the  left  membrana  tympani ;  still  his  hearing  distance  with  that 
ear  is  somewhat  greater  than  on  the  right  side,  in  which  the  mem- 
brane is  not  vascular,  but  is  slightly  opaque. 

The  constitutional  symptoms  in  this  case  were  more  than  usu- 
ally severe,  and  such  as  might  lead  the  practitioner  to  suppose  the 
brain  or  its  membranes  were  engaged.  We  also  learn  from  this 
case  that  inflammation  of  the  tympanum  and  its  membrane  may 
produce  such  a  degree  of  deafness  as  that  the  watch  cannot  be 
heard,  even  when  applied  to  the  ear. 

In  all  probability  the  inflammation  commenced  and  was  ori- 
ginally confined  to  the  tympanal  membrane,  and  afterwards  ex- 
tended to  the  middle,  and,  possibly,  the  internal  ear. 

From  the  latter  stage  of  this  boy's  case  we  also  learn  a  fact 
worthy  of  observation,  namely,  that  it  is  not  the  amount  of  vas- 



cularity,  but  the  degree  of  thickening  and  opacity  in  the  mem- 
brana  tympani,  which  produces  the  deafness. 

The  next  is  a  case  of  acute  myringitis  and  tympanitis  of  one 
pide  ;  and  immediate  recovery  under  the  use  of  mercury. 

C.  L.,  a  female,  aged  21,  applied  at  the  hospital  at  ten  o'clock 
on  the  morning  of  the  18th  of  April,  1846,  for  an  attack  of 
intense  pain  in  her  right  ear.  She  states  that  she  has  not  been 
**  regular**  for  the  last  six  weeks ;  that  she  was  attacked  four  days 
ago  with  catarrh,  attended  with  considerable  stuffing  in  her  nose, 
and  the  other  usual  symptoms  of  that  affection ;  that  she  had 
walked  along  the  sea-shore  the  day  before,  with  a  cold  wind  blow- 
ing upon  her  right  side.  She  went  to  bed  tolerably  well  last 
night,  but  awoke  at  three  o'clock  this  morning  with  a  violent 
beating  pain  in  her  ear,  accompanied  by  a  loud  noise,  which  she 
likens  to  the  ''  puffing  of  a  steam-engine  f  the  pain  resembles 
that  of  a  sharp  instrument  penetrating  through  her  ear  into  her 
head,  which  she  describes  as  most  excruciating.  She  had  also 
Bome  pain  and  soreness  over  that  side  of  the  head ;  she  felt  some 
difficulty  of  deglutition,  owing  to  the  pain  it  caused  her.  Cough- 
ing, sneezing,  or  any  motion  of  the  temporo-maxillary  articulation, 
greatly  aggravated  her  sufferings,  and  gave  her  a  feeling  of  bursting 
in  the  middle  ear. 

She  rose  at  seven  o  clock,  felt  great  sickness  of  stomach,  and 
had  a  well-marked  rigor  whilst  dressing.  She  immediately  ap- 
plied to  a  neighbouring  practitioner,  who  put  some  **  drops**  with 
a  piece  of  cotton  into  her  ear,  which  only  aggravated  her  symp- 
toms. Her  pain  still  continues,  and  the  noise  has  increased; 
there  is  slight  redness  and  great  heat  of  the  auricle.  The  pain  is 
increased  on  making  pressure  over  the  tragus  in  front  of  the 
meatus;  on  pressing  or  percussing  the  mastoid  process  slight  pain 
is  also  complained  of.  The  pain  in  her  ear,  however,  is  not  in- 
creased by  these  means,  nor  is  it  referred  to  the  tympanum.  She 
has  no  pain  beneath  the  meatus,  nor  behind  the  angle  of  the  jaw. 
The  hearing  distance,  with  an  ordinary  ticking  watch,  is  scarcely 
three  inches  in  the  right  ear.  On  closing  the  meatus  of  the  left 
side,  the  noise  is  greatly  increased.     On  examination  with  a  spe- 


Cttlum,  the  auditory  canal  is  found  highly  vascular,  dry,  devoid 
of  cerumen,  and  exceedingly  tender  to  the  touch.  The  membrana 
tympani  has  lost  its  polish,  and  is  of  a  bright,  florid,  generally- 
diffused  red  colour,  spotted  with  small  patches  of  a  deeper  hue, 
like  minute  ecchymoses.  The  projection  of  the  malleus  can  be 
lecognised,  of  a  darker  colour  than  the  surrounding  parts,  with  a 
whiush  line  in  the  centre.  Below  the  malleus,  and  towards  the 
poeterior  part  of  the  membrane,  a  well-defined  vesicle,  about  the 
size  of  a  grain  of  mustard  seed,  and  filled  with  a  brownish  fluid, 
can  be  seen.  Upon  holding  the  mouth  and  nose,  and  pressing 
the  air  into  the  Eustachian  tube,  she  experiences  considerable 
difficulty  in  making  it  pass  up  upon  that  side,  while  it  passes  with 
facility  into  the  tympanum  of  the  left.  The  ear,  or  a  stethoscope, 
held  to  the  right  side  during  this  operation,  readily  perceives,  as 
soon  as  the  air  reaches  the  tympanum,  a  squeeling  and  gurgling 
sound,  as  if  the  air  passed  not  only  through  a  narrow  passage, 
but  through  a  fluid- like  mucus.  This  pressure  of  air  into  the 
tympanum  greatly  aggravates  her  symptoms. 

Upon  looking  into  the  mouth,  the  fauces,  uvula,  and  back  of 
the  pharynx  are  found  nearly  of  their  natural  colour.  Upon  in- 
serting the  forefinger  of  the  right  hand  into  the  mouth,  and  press- 
ing its  point  upwards,  backwards, and  outwards,  towards  the  mouth 
of  the  Eustachian  tube,  considerable  increase  of  pain  is  experi- 
enced in  the  middle  ear.  The  tongue  is  coated;  the  pulse  re- 
gular ;  but  there  is  heat  of  skin,  and  considerable  anxiety  of 
countenance.  The  left  ear  is  natural  in  function  and  appearance. 
This  patient  suffered  from  rheumatism  of  the  upper  extremities 
some  time  ago. 

Four  leeches  were  applied  around  the  meatus,  as  far  in  as  pos- 
sible, and  four  in  the  depression  in  front  of  the  tragus.  She  was 
ordered  to  foment  and  steam  the  ear  over  hot  water,  placed  in  the 
bottom  of  a  long  narrow  mug,  frequently  during  the  day ;  and  a 
purge  was  administered. 

19th.  States  that  she  received  immediate  relief  from  the  leech- 
ing. The  countenance  is  less  anxious,  and  she  slept  well  all 
night;  the  noise  of  a  steam-engine  is  altered  to  a  gurgling  sound; 
the  pain  and  all  other  symptoms  are  relieved ;  the  membrana 


tympani,  however,  remains  nearly  the  same  in  colour,  but  the 
vesicle  has  become  flaccid.  She  was  put  on  the  use  of  calomel 
and  opium  in  small  doses  frequently  repeated ;  a  blister  was  ap- 
plied over  the  mastoid  process ;  the  fomentation  and  warm  vapour 
was  ordered  to  be  continued,  and  a  linseed-meal  poultice  to  be 
applied  to  the  external  ear  at  bed-time. 

20th.  Continues  to  improve.  Noise  changed  to  that  of  the 
ringing  of  bells;  the  pain,  on  pressing  the  mouth  of  the  Eustachian 
tube,  is  much  less;  the  membrana  tympani  is  less  vascular;  the 
general  symptoms  have  all  improved ;  the  mercury  to  be  continued. 

21st.  All  the  symptoms  relieved ;  the  mouth  is  slightly  sore ; 
no  pain  on  pressing  anywhere  around  the  ear  or  meatus ;  all  heat 
and  vascularity  of  auricle  is  removed ;  the  membrana  tympani  has 
lost  its  vascularity,  but  is  slightly  more  opaque,  and  whiter  than 
natural ;  the  vesicle  has  quite  disappeared ;  three  or  four  large 
vessels  can  still  be  seen  coursing  along  the  handle  of  the  malleus. 
Upon  forcing  air  through  the  Eustachian  tube  into  the  tympanum, 
a  slight  gurgling  noise  can  be  perceived  in  the  middle  ear,  and  of 
the  peculiar  sensation  which  it  imparts  the  patient  is  quite  con- 
scious. During  this  operation,  and  while  the  membrane  is  within 
the  field  of  the  speculum,  a  slight  blush  of  redness,  of  a  pinkish 
hue,  is  observed  to  be  produced  in  the  membrane.  The  hearing 
distance  has  increased  to  four  inches.  A  copious  red  deposit  was 
observed  in  the  urine.  She  has  been  slightly  purged  by  the  mer- 
eury ;  ordered  to  lessen  its  dose  to  one  pill  night  and  morning. 

23rd.  Continues  to  improve  in  hearing ;  noise  as  before ;  she 
has  had  no  return  of  pain  in  the  ear ;  the  pain  and  soreness  in  the 
head  gone ;  no  flying  pains  or  other  rheumatic  afiection ;  the  mouth 
is  very  sore :  ordered  to  omit  the  pills,  and  take  the  sixteenth  of 
a  grain  of  oxy muriate  of  mercury  with  decoction  and  tincture  of 
bark  three  times  a  day ;  generous  diet. 

25th.  Continues  to  improve  rapidly ;  membrana  tympani  is 
more  transparent  than  upon  last  examinaUon.  Hearing  distance 
is  increased  to  twelve  inches ;  slight  pain  is  still  felt  on  pressure 
over  the  lower  portion  of  the  mastoid  process,  and  opposite  the 
point  of  the  styloid  process,  in  which  latter  place  it  is  still  increased 
on  coughing.  Ordered  to  continue  the  oxymuriate  and  bark,  and 
to  apply  another  blister. 


All  her  symptoms  have  now  disappeared,  with  the  exception 
of  a  slight  buEzing  occasionally;  the  hearing  is  perfectly  restored^ 

Four  months  later  I  had  an  opportunity  of  examining  this 
youBg  woman  again ;  her  hearing  had  been  quite  restored ;  but  she 
said  that  she  occasionally  suffered  from  a  slight  '*  ticking  noise." 
The  membrane  of  the  drum  upon  the  affected  side  presented  a 
dightly  mottled  appearance,  particularly  towards  its  lower  edge» 
bat  without  an  opacity  of  any  account;  her  hearing  distance  is 
two  feet  less  upon  the  right  side  than  the  left. 

March,  1851.  She  had  a  slight  attack  of  pain  in  the  right  ear, 
accompanied  by  some  deafness  and  redness  of  the  membrana  tym- 
pani,  all  of  which  were  at  once  removed  by  the  application  of 

January,  1852.  She  has  not  had  any  return  of  pain  or  deaf- 
ness; parts  natural;  hearing  normal;  no  tinnitus. 


Case  of  severe  rheumatic  inflammation  of  the  membrana  tym- 
pani  and  cavity  of  the  tympanum,  with  periostitis,  polypus,  &c. 

Mr.  F.,  aged  49,  with  light  hair  and  fair  complexion,  suffered 
several  years  ago  from  a  severe  attack  of  rheumatism,  in  which  his 
heart  was  affected,  caught  while  exposed  to  a  cold  wind  upon  the 
top  of  a  coach  during  a  long  journey ;  since  that  period  he  has 
been  very  liable  to  catch  cold,  in  the  head  particularly,  whenever 
the  feet  are  exposed  to  damp  or  low  temperature.  These  attacks 
of  catarrh  were  characterized  by  violent  fits  of  sneezing  and  run- 
ning at  the  nose,  &c. ;  latterly  his  sense  of  smelling  became  greatly 
impaired,  and  he  perceived  a  stufling  in  the  right  nostril  which 
rendered  him  very  uncomfortable.  During  the  summer  of  1846 
he  was  attacked,  in  addition  to  the  catarrhal  affection,  with  cough, 
expectoration,  and  other  symptoms  of  bronchitis.  Having  reco- 
vered from  this,  he  remained  in  good  health  till  January,  1847, 
on  the  28th  of  which  month,  during  a  period  of  very  wet  and  se- 
vere weather,  his  present  attack  commenced.  His  own  words  are : 
**  About  this  period  I  wore  a  muffler  about  my  neck ;  one  sharp 
morning  I  walked  into  my  office,  laid  it  aside  on  my  arrival,  and, 


being  called  off  suddenly  to  the  Four  Courts,  I  forgot  to  put  it  on 
again.  On  my  way  there  I  felt  a  blast  of  sharp,  cold  air  strike 
my  throat  on  the  right  side,  under  the  ear,  but  I  did  not  pay  much 
attention  to  it,  and  remained  in  Court  most  of  the  day,  with  my 
hat  off  occasionally.  About  two  o'clock  I  felt  a  slight  pain  in  the 
light  ear,  and  got  a  bit  of  cotton  wool  put  into  it ;  about  six  o'clock 
I  returned  home  from  my  office.  I  called  at  my  apothecary's,  who 
dropped  some  warm  oil  and  laudanum  into  my  ear,  which,  for  a 
time,  lessened  the  pain,  but  did  not  completely  remove  it ;  but  I 
was  enabled  to  resume  my  business  as  usual  next  day." 

Mr.  Collins,  to  whom  Mr.  F.  first  applied,  writes  to  me  as  fol- 
lows :  "  When  Mr.  F.  first  called  upon  u\e  he  complained  of  pain 
in  his  right  ear,  and  also  of  slight  shooting  pains  about  that  side 
of  the  head ;  he  looked  a  little  dull  and  heavy,  but  there  was  no 
fever,  quickness  of  pulse,  headach,  deafness,  or  other  symptoms  of 
importance  present.  I  considered  his  attack  to  be  of  a  rheumatic 
or  neuralgic  character,  particularly  as  he  had  suffered  a  few  years 
before  from  severe  rheumatic  fever ;  and  as  the  pain  in  the  ear  was 
what  he  most  complained  of,  I  dropped  some  tincture  of  opium 
and  olive  oil  into  it,  and  applied  a  bit  of  wool  to  prevent  its 
coming  out ;  I  also  ordered  him  an  aperient.  Upon  the  next  even- 
ing Mr.  F.  again  applied  to  me  on  his  return  from  Court,  and 
stated  that  he  had  derived  relief  from  the  drops  until  he  was  again 
exposed  to  cold  and  draughts  that  day :  the  drops  were  again  ap- 
plied and  with  relief.  The  next  day  Mr.  F.  resumed  his  usual 
avocations,  but  the  pain  continued  to  increase,  and  four  leeches 
were  applied  behind  the  ear,  and  a  poppy  fomentation  and  a  poul- 
tice applied  with  considerable  relief,  though  some  slight  pain  still 
remained  in  the  ear  and  the  side  of  the  head.  His  sense  of  smell- 
ing now  returned,  and  continued  perfect  for  a  few  days,  when  it 
was  again  lost.  Mr.  F.  confined  himself  to  the  house  for  the  next 
two  or  three  days,  but  would  not  consent  to  do  so  longer,  as  he 
felt  much  relieved  of  the  pain,  and  business  of  great  importance 
required  his  attention  at  his  office.  In  a  few  days  from  this  date 
his  former  symptoms  returned,  to  relieve  which  he  was  strongly 
recommended  by  a  non-medical  friend  to  drop  into  the  ear  a  lini- 


ment  of  oil  of  turpentine  and  oil  of  cinnamon,  which  I  prepared 
for  him,  but,  having  experienced  no  benefit  from  this,  he  applied 
to  you." 

I  first  saw  this  gentleman  upon  the  13th  February ;  he  com- 
plained of  acute  pain  in  his  right  ear,  which,  as  appears  from  the 
foregoing  account,  had  continued  off  and  on  during  the  previoofl 
fortnight.  The  pain  he  described  as  ''  shooting  from  the  ear  to 
the  temple  and  top  of  the  head,  accompanied  with  a  boiling  and 
pumping  noise,  like  that  of  a  steam-engine  ;^  the  pain  also  appeared, 
according  to  his  own  description,  to  reach  to  the  throat,  without 
making  the  throat  sore ;  it  was  increased  by  sneezing,  but  relieved 
by  pressing  the  hand  upon  the  ear  and  side  of  the  head.  The 
auricle  was  hot  and  somewhat  swollen ;  the  lining  of  the  meatus 
and  auditory  canal  was  red,  tumid,  and  completely  devoid  of  ce- 
rumen ;  the  introduction  of  the  speculum,  and  the  examination, 
caused  a  good  deal  of  pain  from  the  tenderness  of  the  parts ;  the 
membrana  tympani  was  of  a  dark,  brown-red  colour,  had  lost  its 
polish,  and  appeared  to  be  swollen  and  pressed  outwards :  the  pro- 
jection of  the  malleus  could  not  be  discerned ;  pressure  in  firont  of 
the  ear  gave  a  good  deal  of  pain,  but  there  was  no  tenderness  over 
the  mastoid  process.  Rest,  abstinence,  confinement  to  the  house, 
constant  fomentations,  leeches  round  the  meatus,  with  small  doses 
of  blue  pill,  James's  powder,  and  hy oscyamus,  at  night :  and  an 
aperient  in  the  morning,  was  the  treatment  resorted  to  during  the 
next  few  days. 

Upon  the  19th,  his  symptoms,  with  the  exception  of  the  pain 
in  the  ear,  continued  much  the  same ;  he  had  also  flying  pains  of 
a  rheumatic  character  in  the  side  of  the  head,  the  wrists,  feet,  and 
generally  throughout  the  body.  The  pumping  and  boiling  noise 
remained  unabated :  the  deafness  now  became  complete  upon  that 
side.  The  appearance  of  the  ear  continuing  unchanged,  except 
that  the  meatus  was  more  swollen,  it  was  deemed  advisable  to  place 
him  under  the  influence  of  mercury, — an  opinion  in  which  Dr. 
Stokes,  who  saw  him  with  me,  at  that  time  concurred.  He  was  ac- 
cordingly, but  with  some  difficulty,  mercurialized  by  means  of 
small  and  frequently  repeated  doses  of  blue  pill,  calomel,  and 
opium.     When  his  mouth  became  sore,  the  pain  in  the  ear  and 


the  noise  lessened  somewhat^  and  the  general  rheumatic  affection 
disappeared ;  but  the  meatus  and  auditory  canal  now  became  so 
much  decreased  in  caliber,  owing  to  the  thickening  of  the  lining 
of  these  parts,  that  it  was  not  possible  to  gain  more  than  a  glimpse 
of  the  red  and  swollen  membrana  tympani.  The  leeching  and 
blistering  were  continued,  and  the  surfaces  denuded  by  the  latter 
Were  dressed  With  extract  of  belladonna  and  mercurial  ointment. 

March  10th.  The  cuticle  became  detached,  and  a  slight  mu- 
oo'pilfalent  discharge  took  place  from  the  external  meatus ;  the 
ear  was  then  syringed  with  plain  tepid  water ;  he  was  allowed  a 
mote  generous  diet,  and  placed  upon  the  use  of  the  hydriodate  of 
{k>tash,  with  infusion  of  bark  and  tincture  of  orange  peel.  His 
general  health  now  improved ;  he  slept  better,  and  was  able  to  go 
abroad  and  take  exercise ;  the  discharge,  however,  continued  to 
increase,  and  emitted  a  very  offensive  odour ;  and^  at  the  same 
time,  he  began  to  complain  of  a  deep^eated  soreness  all  over  the 
(dde  of  the  head,  behind  the  ear,  but  particularly  over  the  mastoid 
process  and  immediately  below  it.  Towards  the  end  of  March, 
upon  examining  the  ear  carefully  under  a  good  light,  a  small  po- 
lypoid excrescence  of  a  light  red  colour,  growing  from  the  poste* 
nor  wall  of  the  canal,  and  completely  filling  up  that  cavity,  was 
detected ;  this  I  removed  with  the  wire  snare,  and  the  discharge 
then  lessened ;  the  soreness  of  the  side  of  the  head,  the  pumping, 
and  the  deafness,  however,  remained  the  same.  Pressure  over  the 
mastoid  process  and  the  post-aural  region  of  the  head,  very  much 
increased  the  soreness,  and  it  was  now  evident  that  the  periosteum 
covering  these  parts  was  inflamed. 

During  the  latter  part  of  the  month  of  April,  and  all  the  month 
of  May,  the  symptoms  of  periostitis  remained  much  the  same,  and 
the  scalp  itself  became  inflamed,  having  a  dusky,  red  hue,  pitting 
on  pressure,  and  feeling  excessively  sore  to  the  touch.  The  treat- 
ment consisted  in  the  frequent  abstraction  of  blood  from  the  af- 
fected part  by  means  of  a  few  leeches,  and  a  small  cupping-glass 
applied  over  the  leech-bites ;  poulticing,  inunction  with  different 
ointments,  both  of  a  sedative  and  absorbent  nature,  slight  vesi^ 
cants,  &c.,  and  change  of  air.  Bark,  potash,  and  iodine  were  also 
taken  with  a  view  to  improve  the  general  state  of  the  constitution. 


He  had  no  headach,  rigors,  or  perspirations,  and  his  sleep  and  ap- 
petite were  tolerably  good ;  still,  however,  the  pain  continued,  and 
the  dusky  redness  and  tumefaction  of  the  scalp  remained,  although 
there  was  no  evidence  of  suppuration.  It  was  determined,  in  con- 
sultation with  Mr.  Cusack,  to  make  an  incision  down  to  thebone» 
and  thus  free  the  periosteum,  and  give  exit  to  any  matter  which 
might  be  contained  beneath  it.  Accordingly,  upon  the  29th  of 
May,  I  made  a  perpendicular  incision,  about  two  inches  long, 
nearly  parallel  with  the  posterior  margin  of  the  auricle,  by  insert- 
ing a  sharp-pointed  scalpel  down  to  the  bone  at  the  point  of  in^^ 
sertion  of  the  mastoid  muscle,  and  carrying  it  upwards  and  a  little 
backwards.  The  bone  did  not  feel  rough  or  gritty  under  the  knife. 
A  pledget  of  lint  was  inserted  into  it ;  and  when  the  haemorrhage 
had  ceased,  a  llnseed-meal  poultice  was  applied  over  it.  The  wound 
suppurated  kindly,  and  all  the  surrounding  soreness  of  the  scalp 
and  pain  on  pressure  soon  disappeared.  As  the  discharge  from 
the  wound  increased,  that  from  the  meatus  lessened,  and  in  about 
ten  days  the  wound  itself  healed  without  any  exfoliation  of  bone. 
The  pumping  noise  now  ceased  altogether,  the  discharge  from  the 
ear  also  lessened  very  much,  and  all  uneasiness  in  the  parts  ceased. 

During  the  month  of  July,  and  till  the  12th  of  August,  I  only 
saw  Mr.  F.  occasionally.  Upon  examining  the  ear  carefully  at 
this  latter  date,  I  perceived  that  the  meatus  had  regained  its  na-» 
tural  size,  and  I  discovered  another  second  small  polypus  in  the 
situation  of  the  first ;  this  I  also  removed,  and  Mr.  F.  came  to  me 
in  a  day  or  two  to  inform  me  that  the  discharge  had  now  ceased 
altogether,  and  that  the  hearing  had  returned  the  night  after  I  had 
extracted  the  polypus.  He  could  now  perceive  the  ticking  of  a 
watch  at  the  distance  of  an  inch  from  his  ear,  although  he  was 
quite  unconscious  of  it  when  pressed  against  the  auricle  the  day 
I  last  saw  him.  I  could  now  distinguish  the  membrana  tympani 
perfectly ;  it  was  of  a  dull  white  colour,  evidently  much  tUck- 
ened,  but  not  perforated  in  any  part. 

September  3rd.  He  has  continued  to  improve  in  every  respect ; 
his  health  and  spirits  are  quite  restored ;  all  discharge  from  the  ear 
has  ceased ;  the  tinnitus  aurium  now  consists  in  a  slight  '*  booing** 
which   appears  occasionally :  the  hearing  is  slowly  returning. 

252  ACUTB  HTRnrams  with  otitis. 

The  snuffling  and  loss  of  smell  I  now  found  to  be  caused  in  a  great 
measure  by  a  small  gelatinous  polypus  which  filled  up  the  cavity 
of  the  right  anterior  naris,  upon  removing  which,  both  the  nasal 
respiration  and  the  sense  of  smell  were  much  improved. 

This  case  is  instructive,  as  showing  the  rheumatic  character  of 
some  of  the  inflammations  of  the  ear,  and  as  exhibiting  the  occa- 
sional failure  of  the  mercurial  treatment  to  cut  short  the  disease, 
particularly  if  it  has  advanced  to  any  height,  as  this  had.  The 
discharge  came  from  the  external  ear  and  the  polypus.  This  mor- 
bid polypoid  growth,  thus  appearing  during  the  progress  of  an 
inflammation,  should  always  lead  the  practitioner  to  suspect  mis- 
chief going  on  in  the  neighbourhood,  and  should  cause  him  to  ex- 
amine with  great  care  the  condition  of  the  mastoid  process  and  its 
coverings,  although  neither  the  exbtence  of  a  polypus,  nor  the 
foDtor  or  dark  colour  of  the  discharge,  are  of  themselves  a  suffici- 
ent proof  of  caries  or  denuded  bone.  The  appearance  of  perios- 
titb,  even  at  this  late  period,  is  not  an  unusual  consequence  of 
violent  otitis ;  the  inflammation  may  spread  from  the  periosteum 
lining  the  bony  portion  of  the  meatus ;  or  the  mastoid  cells  may, 
and  often  are,  the  seat  of  inflammation,  and  this  inflammation  may 
extend  from  the  layer  of  bone  which  covers  them  to  the  perios- 
teum. If  not  relieved  by  such  local  and  general  means  as  were 
made  use  of  in  the  early  part  of  the  foregoing  case,  the  surgeon 
should  not  hesitate  to  cut  down  upon  the  covering  of  the  bone, 
and  divide  it  fairly  for  an  inch  or  more  of  its  length.  Almost  im- 
mediate ease  follows  this  operation,  even  though  we  fail  to  disco- 
ver the  existence  of  pus ;  and,  moreover,  delay  after  a  certain  period 
may  prove  fatal.  A  thin  shell  of  bone  is  occasionally  thrown  off 
in  such  cases,  but  not  always.  Generally  speaking,  the  otorrhcea 
lessens  when  the  discharge  from  the  wound  is  fully  established, 
although  there  may  not  be  any  communication  whatever  between 
the  parts  from  which  these  discharges  come.  When  this  pain  over 
the  mastoid  process  appears  early  in  the  disease,  and  is  accompa- 
nied by  an  erysipelatous  redness  and  cedema  of  the  scalp,  we  should 
not  hesitate  in  having  recourse  to  incision  immediately. 

We  have  in  this  case  another  remarkable  example  of  a  mecha- 
nical impediment,  such  as  the  polypus,  so  completely  obstructing 


sound,  that  a  watch  held  to  the  ear  was  not  perceived,  although 
hearing  returned  within  a  few  hours  when  that  mechanical  obstruc- 
tion was  removed.  There  can  be  little  doubt  of  the  middle  ear 
having  been  engaged  in  this  inflammation,  yet  we  have  no  evi* 
dence  of  perforation  of  the  membrane  of  the  drum  having  taken 
place.  The  only  treatment  subsequently  employed  with  Mr.  F. 
was  that  of  occasionally  washing  over  the  auditory  canal  and  mem- 
brana  tympani  with  a  solution  of  nitrate  of  silver. 


Besides  the  acute  form  of  the  disease,  attended  by  violent  pain, 
&c.,  already  described,  there  is  a  description  of  sub-acute  inflamr 
fncilion'*  of  the  membrana  tympani,  with  which  I  have  been  long 
familiar,  and  which,  although  perfectly  painless,  is  equally  destruc- 
tive to  hearing.  It  generally  appears  in  persons  between  15  and 
30.  The  first  symptom  to  which  the  patient  s  attention  is  directed 
is  deafness,  which  has  appeared  rather  suddenly.  It  may  be,  but  is 
not  necessarily,  accompanied  by  tinnitus ;  but  there  is  always  a  feel- 
ing of  stuffing  in  the  ear ;  the  same  stuffing  is  felt  in  the  nose  and 
frontal  sinus ;  the  patient  complains  of  there  being  a  veil  between 
him  and  the  sound.  The  tympanal  cavity  is  usually  free ;  and 
when  it  is  not,  blowing  the  nose  or  sneezing  sometimes  suddenly 
restores  the  hearing :  and  this  is  one  of  the  causes  why  the  disease 
is  so  frequently  neglected,  the  patient  expecting  a  similar  effisct 
from  day  to  day.  The  nature  of  the  disease  is  only  to  be  learned 
by  a  careful  inspection  of  the  membrane,  which,  if  we  see  the  dis- 
ease early,  is  always  of  a  pink  colour,  of  a  tint  somewhat  paler  than 
that  of  the  monthly  rose.  Through  this,  dispersed  in  various  di- 
rections, we  may  observe  in  some  cases  a  few  long,  tortuous  vessels. 
The  transparency  and  polish  of  the  membrane  are  seldom  much 
affected  at  first.  The  auditory  canal  does  not  usually  exhibit  signs 

*  Dr.  Kramer  has,  in  the  latest  edition  of  his  Ohrenkrankheiten^  foand  mach  faalt 
with  my  classification  of  the  inflammations  of  the  membrana  tympanL  Upon  a  carefb] 
revision  of  my  opinions,  and  five  years'  additional  experience  of  these  diseases,  I  see  no 
reason  to  discard  any  of  the  forms  of  disease  which  I  originally  published,  although  the  pre- 
sent arrangement  is  somewhat  different  Had  Dr.  Kramer  accustomed  his  eye  to  distin- 
guish the  different  ophthalmic  inflammations,  he  might  have  been  able  to  appreciate  the 
various  shades  of  colour  on  the  membrana  tympani. 


of  disease,  but  the  cerumenous  secretion  is  arrested.  Generally 
speaking,  there  are  no  constitutional  symptoms  present,  and  when 
tinnitus  is  an  accompaniment,  it  is  usually  of  a  very  light  charac- 
ter, resembling  a  slight  buzzing  or  singing.  If  allowed  to  proceed 
unchecked,  the  membrane  becomes  thickened  and  remarkably 
opaque,  from  lymphy  deposits,  and  the  deafness  which  ensues  is 
of  a  most  irremedial  nature.  Collapse  or  drawing  inwards  of  the 
membrana  tympani  does  not  usually  follow  this  form  of  the  affec- 
tion, but  ulceration,  even  to  perforation  of  the  membrane  of  the 
drum,  is  not  an  uncommon  attendant  upon  it. 

This  disease  is  slow  in  its  progress,  and  requires  very  careful 
watching.  Cases  of  this  nature  have  been,  I  feel  convinced,  re- 
peatedly treated  as  '*  nervous  deafness.**  I  am  inclined  to  think 
that  it  is  a  true  myringitis,  in  which  the  inflammation  is  seated 
in  the  fibrous  layer  of  the  membrane.  In  this  disease  mercury  is 
just  as  necessary  as  in  that  already  detailed ;  it  should,  however, 
be  given  after  a  different  fashion :  to  be  effectual,  it  must  be  slowly 
introduced  into  the  system,  so  as  to  produce  a  steady  and  gradual 
effect.  The  mouth  should  be  kept  sore  until  there  is  a  decided 
improvement  both  in  the  vascularity  and  in  the  hearing,  or  until 
all  hope  of  restoration  has  been  abandoned,  or  other  circumstances 
induce  us  to  relinquish  this  mode  of  treatment.  After  the  consti- 
tution has  been  fully  affected  by  the  mineral,  the  bichloride,  given 
in  doses  from  the  sixteenth  to  the  eighth  of  a  grain,  dissolved  in 
proof  spirits,  and  taken  in  half  an  ounce  of  the  cold  infusion  of 
bark,  and  a  scruple  or  half  a  drachm  of  Huxham*s  tincture,  three 
times  a  day,  will  be  found  highly  efficacious.  The  preparations 
of  iodine  are  also,  in  the  advanced  stages  of  the  disease,  worthy  of 
trial ;  but  I  do  not  think  that  the  preparations  and  combinations 
of  iron  produce  in  aural  inflammations  the  same  benefit  which  they 
do  in  constitutions  labouring  imder  ophthalmic  affections  of  alike 

Counter-irritation  over  the  mastoid  process,  change  of  air,  re- 
moval to  the  sea,  and  generous  living,  will  hasten  the  cure. 

To  relieve  tinnitus  aurium,  after  the  inflammatory  action  has 
been  subdued,  or  the  original  disease  which  produced  it  has  sub- 
sided, and  particularly  in  cases  where  we  find  this  symptom  pre- 


sent  without  any  apparent  lesion  of  the  parts  we  are  able  to  in- 
spect,.! have  found  the  preparations  of  the  Arnica  montana  of  de* 
cided  benefit ;  indeed  it  is  the  only  medicine  with  which  I  am 
acquainted  that  seems  to  possess  a  specific  power  over  this  an- 
noying and  usually  most  intractable  complaint.  The  preparation 
I  find  most  efficacious  is  the  tincture  both  of  the  flowers  and 
leaves,  of  which  the  patient  should  commence  by  taking  fifteen 
drops  in  a  table-spoonful  of  the  infusion  of  Arnica,  with  some  cor- 
dial tincture  three  times  a  day.  After  a  few  days  the  dose  should 
be  increased  one  or  two  drops  daily,  till  it  reaches  thirty,  or  even 
more,  unless  headach  or  giddiness  be  produced,  when  we  should 
at  once  lessen  the  dose,  or  omit  the  medicine  altogether  for  a  short 
time.*  The  state  of  the  bowels  should  be  carefully  attended  to 
during  the  administration  of  this  drug. 

So  long  as  any  vascularity  or  recent  deposit  exists  in  the  raem- 
brana  tyrapani,  notwithstanding  manifest  improvement  of  the 
hearing,  we  should  not  desist  from  employing  means  to  remove 
it,  as  these  cases  are  of  a  most  insidious  and  protracted  character. 
When  ulceration  exists,  we  should  touch  the  part  daily  with  a 
solution  of  lunar  caustic,  applied  with  a  fine  brush. 

In  all  the  inflammations  of  the  middle  and  external  ear,  the 
secretion  of  cerumen  is  arrested,  and  it  is  long  aftier  the  disease  has 
been  relieved,  that  the  cerumenous  glands  resume  their  healthy 
functions,  the  auditory  passage  remaining  dry  and  its  lining  scaly : 
or  the  wax  which  is  produced  being  insufficient  in  quantity,  of  a 
very  dark  colour,  and  soon  becoming  hard  and  inspissated.  This 
deficiency  of  cerumen,  which  is  but  a  symptom,  is  often  set  down 
as  a  disease,  and  various  applications,  such  as  ox-gall,  creasote,  gly« 
cerine,  &c.,  have  been  recommended  to  restore  it.  I  find,  how- 
ever, that  nothing  produces  a  healthy  action  in  the  parts  so  soon, 
while,  at  the  same  time,  it  immediately  supplies  the  best  artificial 

*  The  folloiving  is  the  formula  for  the  tincture: — One  ounce  and  a  half  of  ih^flower$ 
to  a  pint  of  rectified  spirit  of  wine ;  macerate  for  fourteen  days  and  strain ;  or,  of  the 
leaves^  the  same  quantity  infused  for  a  similar  period  in  proof  spirits.  In  prescribiiv 
these  I  usually  order  them  in  equal  proportions. 

Dr.  Neligan  says :  ^*  This  tincture  may  be  readily  prepared  by  percolation,  haring 
preTiously  macerated  the  flowers  with  a  little  of  the  spirit  for  twenty-four  hours ;  or  it 
may  be  prepared  with  the  cat  and  bruised  root  in  the  proportloa  of  Sii.  of  the  root  to  Qj. 
of  rectified  spirit.     Dose,  £  3flB.  to  f.  ^iJ'—MtdimMt  and  thtw  Uu9> 


saccedaneum,  as  the  soft  brown  citrine  ointment,  applied  to  the 
auditory  passage  in  a  melted  state  with  a  soft  brush. 

The  following  case  affords  a  good  example  of  the  sub-acute 
form  of  the  disease,  of  the  inattention  paid  to  the  early  symptoms 
of  deafness  by  practitioners  in  general,  and  the  ef&cacy  of  anti- 
phlogistic treatment.  As  the  subject  of  this  case,  Mr.  S.,  then 
aged  19,  was  a  gentleman  of  very  great  intelligence,  I  give  the 
history  of  his  case,  as  far  as  possible,  in  the  words  of  the  narrative 
with  which  he  has  furnished  me :  **  About  the  year  1836  I  felt 
symptoms  of  deafness  in  both  my  ears  for  the  first  time,  but  on 
the  application  of  blisters  these  symptoms  passed  away.  From 
being  but  a  child  at  the  time,  I  have  an  imperfect  recollection  of 
the  peculiar  symptoms  of  my  case.  Again,  in  1840,  I  became 
quite  deaf  in  my  right  ear:  this  I  mentioned  to  our  family  physi- 
cian, but  for  some  time  he  treated  it  as  a  joke,  telling  me  merely 
that  I  was  idle  and  wished  for  some  holidays;  however,  on  my 
frequently  asserting  that  I  really  was  deaf,  he  directed  me  to 
syringe  my  ear  night  and  morning,  and  afterwards  he  dropped 
some  liquid  into  it  which  he  prescribed  for  me,  but  he  did  not 
make  any  particular  examination  of  my  ear.  I  continued  to  fol- 
low his  advice  for  some  weeks,  but  without  any  beneficial  effect. 
I  was  then  advised  to  get  some  rusty  bacon,  cut  it  into  small 
shreds,  and  put  one,  morning  and  evening,  into  my  ear, — but  with 
no  better  success.*  At  last  I  applied  a  blister  behind  my  ear, 
and  kept  it  open  for  six  months.  This  treatment,  which  may, 
and  very  probably  would,  as  experience  has  since  shown  me,  have 
been  successful,  had  it  been  resorted  to  in  the  first  instance,  was 
then  of  no  avail.  On  two  subsequent  occasions,  about  Christmas, 
1841,  and  July,  1842, 1  had  an  ear-ache  in  that  ear,  and  the  only 
application  which  gave  me  relief  was  dropping  warm  laudanum  . 
into  it-t    At  the  close  of  September,  1845,  I  felt  my  left  ear  one 

*  This  is  a  very  popular  remedy  in  Ireland,  and  is  frequently  prescribed  by  medical 
practitioners.  In  cases  of  deafness  solely  the  result  of  a  deficiency  of  cerumen  (very  rare 
cases,  by  the  way)  it  is  innoxious,  and  may  be  effectual,  but  in  no  other  case  that  I  am 
aware  of  is  it  at  all  applicable. 

f  Laudanum  dropped  into  the  ear  is  one  of  the  most  popular  remedies  for  ear-ache, 
and  in  many  instances  it  affords  reliefl  I  do  not  object  to  its  application  as  a  means  of 
lessening  pain,  but  I  do  as  a  remedial  agent,  while  the  eaute  of  the  pain  is  uninvestigated, 
and  not  treated  according  to  the  estabUdied  mlea  for  lessening  inflammation,  &c. 


morning  as  if  it  were  stopped,  and  perceived  a  buzzing  sound  in 
ity  such  as  one  feels  on  applying  a  sea-shell  to  it.  This  noise  was 
increased  at  night  when  I  lay  in  bed ;  it  then  resembled  a  constant 
loud  hissing.  I  became  very  deaf,  and  my  difficulty  of  hearing 
increased  daily ;  I  also  experienced  an  uneasy  sensation,  and  a 
feeling  of  stuffing,  in  this  ear,  but  no  pain."^ 

On  the  21st  of  the  November  following  I  first  saw  this  young 
gentleman.  I  found,  in  additioh  to  the  symptoms  already  de- 
scribed, a  bright  pink  hue  diffused  over  the  left  tympanal  mem- 
brane, which,  however,  had  not  lost  its  polish,  nor  become  opaque. 
He  was  with  difficulty  able  to  inflate  the  drum,  and  when  he  did 
so,  the  stream  of  air  caused  a  slight  squeeling  and  a  mucous 
gurgling  in  the  middle  ear.  The  external  meatus  on  both  sides 
was  dry,  devoid  of  cerumen,  and  somewhat  redder  than  natural. 
The  throat  was  normal.  It  was  evidently  a  case  of  sub-acute  in- 
flammation of  the  membrana  tympani,  of  the  mucous  membrane 
lining  the  cavity  of  the  drum,  and  the  Eustachian  tube :  with  mu- 
cous engorgement  of  the  middle  ear.  Upon  the  right  side  the  mem- 
brana tympani  was  thickened  and  opaque,  and  two  or  three  large 
red  vessels  spread  over  its  surface,  but  the  air  passed  up  with  fa- 
cility. Six  leeches  were  immediately  applied  to  the  left  ear,  three 
round  the  meatus,  and  three  in  front  of  the  tragus,  and  warm  stupes 
and  fomentations  prescribed. 

Upon  the  29th  his  symptoms  remained  unabated  and  the  ap- 
pearances  unaltered,  so  I  immediately  put  him  on  the  use  of  mer- 
cury ;  and  at  the  same  time  a  repetition  of  the  leeches  round  the 
meatus,  and  the  application  of  blisters  over  the  mastoid  process, 
was  had  recourse  to.  As  soon  as  the  mouth  became  slightly  af- 
fected, I  observed  that  the  vascularity  of  the  right  ear — that 
originally  affected —  was  very  much  lessened,  and  I  then  recom- 
mended the  application  of  leeches  and  blisters  to  that  also ;  and 
had  the  satisfaction  to  find,  that  the  hearing  began  to  improve 
gradually  on  this  as  well  as  on  the  left  side. 

As  Mr.  S.  improved  daily  the  mercury  was  omitted,  and  he 
commenced  the  use  of  bark  and  hydriodate  of  potash.  Towards 
the  end  of  December  he  was  so  much  improved  that  I  disconti- 
nued my  attendance,  and  I  lost  sight  of  him  for  a  short  time.    In 



the  beginning  of  January,  1846,  however,  he  again  applied  to  me : 
worse  than  ever.  The  weather  had  been  remarkably  damp  and  un- 
favourable ;  he  was  much  exposed  to  its  influence,  and  had  caught 
cold,  which,  to  use  his  own  expression,  had  *^  pitched  in  his  ears.'* 
He  was  then  so  deaf  that  he  could  with  great  difficulty  under- 
stand what  was  said  to  him,  although  addressed  in  a  distinct  and 
loud  voice.  The  vascularity  had  returned  in  the  left,  and  partially 
in  the  right  ear,  and  the  mucous  engorgement  of  the  tympanal  ca- 
vities was  more  manifest.  The  same  course  had  to  be  pursued 
as  on  the  former  occasion ;  he  was  confined  to  the  house  for  a 
month,  and  kept  under  the  gentle  influence  of  mercury  for  the 
last  three  weeks  of  that  time.  I  desired  him  to  try  occasionally 
to  press  the  air  into  the  drums,  particularly  when  blowing  the 
nose ;  and  as  the  inflammatory  condition  subsided  he  was  enabled 
to  do  this  with  greater  facility.  Each  time  tlieair  passed,  his 
hearing  was  improved.  At  the  end  of  a  month  the  mercury  was 
discontinued  and  the  leeching  given  up.  Small  blisters  were 
kept  open  behind  the  cars,  and  the  use  of  bark  and  hydriodate  of 
potash  was  persisted  in  for  some  weeks  longer.  In  the  following 
November  all  trace  of  disease  had  been  removed  from  the  left 
ear,  and  the  tympanal  membrane  of  the  right  was  much  thin- 
ner, and  much  less  vascular  and  opaque,  than  when  I  first  saw 
him  in  1845; — his  hearing  was  perfect  upon  the  leftside,  and  in- 
creased on  the  right  to  fourteen  inches.  He  has  remained  well 
from  that  time  to  the  date  of  the  publication  of  this  work. 

In  the  foregoing  case  we  have  a  good  example  in  the  right 
ear, — which,  when  I  first  saw  it,  was  in  the  condition  of  chronic 
inflammation, — of  the  eflects  of  neglect,  and  also  of  the  efficacy 
of  the  mercurial  and  antiphlogistic  treatment,  not  only  in  the  re- 
moval of  recent  disease,  but  in  the  improvement  of  an  afiection  of 
several  years'  standing. 

I  could  enumerate  several  other  well-marked  cases  of  this  dis- 
ease, were  it  necessary,  all  presenting  the  same  appearances,  and 
cured  by  the  same  means,  but  in  very  few  has  treatment  been 
attended  with  the  same  happy  results  in  an  ear  so  long  afiected 
as  in  this.  Generally  only  one  ear  is  affected  at  a  time,  but 
sooner  or  later  the  other  usually  becomes  engaged.     I  feel  con- 


vinced  that  many  cases  of  incurable  deafness  have  arisen  from 
this  disease. 

In  the  treatment  of  the  malady,  the  efficacy  of  tobacco-smoke 
should  not  be  omitted.  Where  there  is  redness  and  relaxation  of 
the  mucous  membrane  of  the  throat  and  nose,  with  much  *'  stuf* 
fing  in  the  head,"  and  mucous  engorgement  of  the  middle  ear,  the 
moderate  use  of  tobacco-smoke  inhaled  from  a  good  cigar,  and 
gently  puffed  out  through  the  nose,  will  be  found  beneficial.  It 
certainly  acts  as  a  stimulant  and  astringent  on  the  surface  with 
which  it  comes  in  contact,  and  it  is  not  improbable  that  some  of  it 
may  find  access  to  the  cavitas  tympani.  I  understand  soldiers  are 
in  the  habit  of  forcing  tobacco-smoke  into  their  ears  when  they 
become  deaf.  In  strumous  myringitis,  and  also  in  chronic  or  sub- 
acute inflammation  of  the  lining  of  the  tympanum,  tobacco-smoke 
is  often  of  service. 

SyphUitio  MtfringiHs. — Although  practitioners  who  treat  sy- 
philitic diseases  upon  a  large  scale  appear  to  be  aware  of  the 
fact,  that  venereal  occasionally  causes  deafness,  I  cannot  find  any 
authority  which  has  noticed  the  disease  I  am  about  to  describe* 
The  deafness  which  sometimes  accompanies  the  secondary  form 
of  syphilis  is  generally  believed  to  be  caused  by  inflammation 
and  ulceration  extending  from  the  throat  through  the  Eustachian 
trumpet  into  the  middle  ear;  such  may,  imder  certain  circum- 
stances, no  doubt,  occur,  and  produce  destructive  inflammation 
and  suppuration  in  this  cavity,  although  I  have  never  seen  such 
a  case  myself,  nor  have  I  met  with  a  well-authenticated  instance 
of  it  recorded.  The  English  writers  upon  aural  diseases  have 
altogether  omitted  syphilitic  affections  of  the  ear,  as  have  also 
Kramer  and  most  of  the  continental  writers,  with  the  exception 
of  Lincke  and  Frank,  the  latter  of  whom  enumerates  two  forms, — 
the  first,  external  syphilitic  otitis,  in  which  secondary  ulcerations 
occur  in  the  auditory  canal,  accompanied  by  other  well-determined 
symptoms  of  the  disease;  but  these  are  already  known  to  the  sur« 
geon,  they  resemble  ulcerations  on  the  margins  of  the  tarsal  car- 
tilages, and  are  sometimes  the  consequences  of  rupia  upon  the 
auricle,  in  the  vicinity  of  the  meatus  (see  page  169).  Under  the 
head  of  otitis  interna,  he  describes  the  result  of  lues,  which,  he 

T  2 


says,  arises  either  as  a  reflex  of  the  disease  in  the  ear  itself,  or  is 
propagated  through  the  Eustachian  tube  from  the  throat.  He 
says  this  dbease  is  accompanied  by  great  pain,  and  often  termi- 
nates in  suppuration  of  the  middle  ear,  destruction  of  the  tympa- 
nal membrane,  and  caries  of  the  temporal  bone.  It  is  evident, 
however,  from  his  description,  that  the  disease  of  which  he  speaks 
is  the  ordinary  suppuration  of  the  cavity  of  the  tympanum,  with 
s  neglected  otorrhosa,  and  in  nowise  characterized  by  any  peculiar 
syphilitic  symptom. 

Lincke's  usual  accuracy  and  observation  seem  to  have  deserted 
him  when  writing  his  chapter  upon  **  Otitis  Syphilitica  \  for,  while 
the  affection  now  under  consideration  seems  totally  to  have  es- 
caped his  observation,  he  has,  with  most  laborious  German  assi- 
duity, collected  together  a  multiplicity  of  authorities  bearing  upon 
the  subject  of  what  are  supposed  to  be  syphilitic  diseases  of  the 
ear,  but  not  one  of  which  he  himself  has  verified.  Thus  he  enu- 
merates from  the  works  of  CuUerien  and  Plisson  chancres  both  on 
the  auricule  and  in  the  meatus.  He  also  gives  a  description  of 
chancres,  *'  if  they  arise  near  or  on  the  membrana  tympanV' !  but, 
like  Frank,  his  descriptions  are  chiefly  in  reference  to  the  syphi- 
litic otorrhoea,  the  result  of  inflammation  and  ulceration  extend- 
ing from  the  throat  or  nose,  a  disease,  the  existence  of  which  yet 
remains  to  be  proved  by  original  observers,  not  system-makers  or 

While  Lincke's  work  must  ever  remain  a  most  valuable  book 
of  reference,  it  is  high  time  for  those  who  wish  to  advance  the 
science  of  aural  surgery  to  cast  off*  the  incubus  of  authority,  and 
by  patient  investigation  and  originality  of  observation  to  establish 
facts.  Kramer  deserves  much  more  credit  for  omitting  all  notice 
of  an  affection  which  it  is  evident  he  had  never  himself  observed, 
than  those  writers  who,  with  equal  want  of  knowledge,  have  en- 
deavoured, by  collecting  out  of  a  variety  of  obscure  writers  some 
ill-recorded  cases,  to  establish  an  untenable  theory. 

In  1835,  M.  Lallemand,  in  his  Clinical  Lectures  on  Syphilitic 
Diseases,  as  reported  by  Dr.  Waters,  related  four  cases  of  syphilitic 
deafness  cured  by  ante-venereals.  (See  Medical  Times,  for  27th 
September.)    Were  medical  literature  to  be  searched  from  end  to 


end,  I  do  not  think  such  instances  of  unwarranted  assertion  and 
loose  writing  could  be  found.  The  state  of  the  membrana  tym- 
pani  was  never  inspected,  nor  the  condition  of  the  middle  ear  ex- 
plained, in  any  one  of  these  cases. 

The  disease  which  I  am  about  to  describe  is  an  inflammation 
of  a  specific  character,  occurring  in  the  membranes  of  the  tym- 
panal cavity,  but  chiefly  exhibited  in  the  external  membrane  of 
the  drum.  All  the  cases  I  have  seen  of  this  affection  occurred  in 
young  men,  and  generally  those  of  fair  complexions  and  blue 
eyes,  who  had  had  primary  sores  upon  the  genitals  from  six  to 
twelve  months  previously,  which  sores  were  of  rather  a  deceptive 
character,  so  that  mercury  was  seldom  given  in  the  first  instance, 
at  least  in  a  legitimate  form.  These  sores  were  usually  tedious  in 
healing,  and  followed  by  papular  eruptions  and  sore  throats,  for 
which  mercury  was,  in  most  of  the  cases,  taken  irregularly.  Bu- 
boes were  not  a  common  attendant,  nor  had  iritis  ensued  in  any 
of  the  instances  of  well-marked  venereal  myringitis  which  fell  un- 
der my  notice ;  but,  generally  speaking,  eruptions,  copper-coloured 
blotches,  fissures  and  ulcers  of  the  tongue,  with  loss  of  strength, 
and  slight  nocturnal  pains,  existed  previous  to  the  aural  afiec- 
tion,  which  should,  I  think,  be  ranked  as  a  tertiary  symptom. 
In  almost  every  case  which  I  have  witnessed,  the  disease  appeared 
suddenly,  as  an  eruption  was  fading  ofi*;  in  two,  it  came  on  at  a 
later  period,  and  was  accompanied  by  loss  of  hair;  in  most  it  ap- 
peared in  the  upper  or  middle  ranks  of  life.  In  some  cases  there 
is  at  first  a  sensation  of  fulness  in  the  head,  and  often  vertigo 
upon  stooping  or  rising  up  suddenly,  and  the  patients  have  usu- 
ally a  feeling  of  fulness  within  the  ear;  but  in  no  instance  have  I 
seen  it  accompanied  by  acute  pain,  in  which  circumstances  it  re- 
sembles the  sub-acute  form  of  inflammation  already  described,  and 
is  therefore  placed  as  a  subdivision  of  that  species ;  but  upon  in- 
spection, the  amount  of  redness  and  vascularity  will  be  found  very 
much  greater  than  the  latter;  and  in  this  consists  one  of  the  chief 
characteristics  of  this  disease,  that  while  it  is  unaccompanied  by 
local  pain,  as  in  the  sub-acute  inflammation,  the  membrana  tyra- 
pani  will  be  found  to  present  an  amount  of  redness  equal  to,  and 
sometimes  exceeding,  that  seen  in  acute  myringitis.   The  redness 


has  generally,  howemer,  a  brownish  hue  in  the  syphilitic  form, 
which  is  not  observable  in  that  just  alluded  to.  There  is  not,  at 
first,  much  loss  of  polish,  but  in  a  short  time  the  membrane  as- 
sumes a  fuzzy  appearance.  The  auricle  and  meatus  I  have  not 
seen  affected  more  than  in  the  sub-acute  form ;  both  ears  are  usu- 
ally attacked  at  the  same  time.  The  amount  of  deafness  is  always 
very  great,  and  is  the  symptom  that  first  attracts  the  patient's  at- 
'  tention,  and  it  seldom  varies.  Tinnitus  is  not  usually  present,  but 
in  two  cases  which  I  possess  the  notes  of,  the  deafness  was  ushered 
in  by  a  very  loud  noise,  which  passed  away  after  a  few  days. 
This  inflammation  does  not  end  in  muco-purulent  discharge 
from  the  tympanum,  the  surface  of  the  membrana  tympani,  or 
the  sides  of  the  auditory  canal ;  nor  have  I  seen  lymph  effused 
upon  the  membrane,  as  in  the  more  violent  and  painful  forms  of 
otitis ;  but  from  its  brownish-red  colour  in  the  very  early  stage* 
from  a  yellowish  speckled  opacity,  which  is  generally  observable  in 
it  on  the  subsidence  of  the  redness,  and  from  the  intense  degree  of 
thickening  and  dulness  which  were  present  in  some  cases,  which 
were  evidently  the  result  of  syphilitic  disease,  I  am  inclined  to 
think  that  lymph  is  largely  effused  between  the  laminse,  or  upon 
the  inner  surface  of  the  membrana  tympani.  Two  of  the  worst 
'  cases  of  non-congenital  deafness  I  ever  saw  appeared  to  have  been 
the  result  of  syphilitic  inflammation,  and  in  both  there  was  great 
thickening,  opacity,  and  insensibility  of  the  membrane.  I  am  also 
inclined  to  think  that  syphilis  has  played  a  more  extensive  part 
in  the  production  of  deafness  than  the  profession  is  aware  of. 

The  following  case  of  syphilitic  inflammation  of  both  tympa- 
nal membranes,  with  rapid  recovery  under  mercurial  treatment,  is 
characteristic  of  the  affection. 

Mr.  A.  B.,  aged  30,  had  a  doubtful-looking  sore  upon  the 
penis,  twelve  months  previous  to  my  seeing  him.  Considerable 
doubt  was  expressed  as  to  the  genuine  syphilitic  character  of  the 
Bore ;  but  it  healed  under  local  treatment.  Some  months  subse- 
quently he  had  a  bubo  in  the  right  groin,  and  a  small  abscess  also 
formed  on  the  under  side  of  the  urethra ;  he  then  rubbed  in  mer- 
cury, and  was  confined  to  the  recumbent  posture,  until  the  swell- 
ing of  the  groin  had  completely  subsided.     After  tiiis  he  expe- 


rienced  great  weakness  and  lassitude,  and  suffered  for  several 
weeks  from  sore  throat.  These  symptoms  were  relieved  by  re- 
moval to  the  country ;  but  on  his  return  to  town,  an  eruption  ap- 
peared extensively  on  the  genitals,  thighs,  and  abdomen,  and  he 
had  also  some  slight  deafness.  He  was  benefited  by  the  use  of 
hydriodate  of  potash ;  but  the  eruption  came  and  went,  both  on 
its  original  seat  and  on  the  chest  and  extremities,  during  the  next 
few  weeks.  I  first  saw  him  with  Mr.  John  Evans,  in  the  middle 
of  October,  1847 ;  he  had  then  no  sore  throat,  but  a  fresh  crop  of 
eruption,  in  the  form  of  brownish  spots  interspersed  with  small 
pimples,  had  appeared  generally  over  the  back  and  the  outer  sides 
of  the  arms.  He  had  also  become  exceedingly  deaf,  hearing  the 
watch  only  when  pressed  against  the  auricle,  and  he  complained 
of  a  sense  of  giddiness  and  fulness  in  the  head,  but  had  no  pain 
whatever  in  the  ears,  nor  any  snuffling  in  the  nose.  He  stated, 
that  his  deafness  had  occurred  suddenly,  a  few  hours  after  rising 
in  the  morning  some  days  before ;  that  he  had  tinnitus  at  the  com- 
mencement, but  that  it  had  now  nearly  vanished.  Upon  inspec- 
tion, the  auditory  canal  was  found  dry,  and  the  membrana  tym- 
pani  of  an  uniform  dark  brown-red  colour,  so  that  the  situation 
of  the  hammer  bone  was  not  easily  recognisable.  There  was  no 
ulceration  observable,  nor  any  alteration  in  the  plane  of  the  mem- 
brane :  but  the  light  was  not  reflected  from  it  in  the  ordinary 
manner,  thus  showing  that  it  had  lost  its  polish.  These  appear- 
ances were  nearly  the  same  upon  both  sides.  He  was  able  to  in- 
flate the  drums  perfectly,  and  auscultation  afforded  no  evidence 
either  of  contraction  of  the  audito-faucial  passages,  or  of  any  accu- 
mulation of  fluid  within  the  tympana. 

The  treatment  consisted  in  the  application  of  leeches  round  the 
meatus  every  second  day,  and  the  use  of  calomel  and  opium  in 
small  and  frequently  repeated  doses.  This  mode  of  administering 
the  mineral  disagreeing,  we  were  obliged  to  discontinue  it,  and 
substitute  inunction  in  its  stead.  The  deafness  and  the  appear- 
ance in  the  ear  remained  unaltered  until  the  morning  on  which 
salivation  was  produced,  and  then  hearing  was  restored  almost  mi- 
raculously, and  the  next  day  the  redness  and  vascularity  in  the 
ears  had  almost  disappeared.     Gentle  pytalism  was  kept  up  for 


some  days  longer.  He  has  not  since  had  any  return  either  of  the 
deafness  or  other  syphilitic  symptoms. 

I  attended  a  case  with  Mr.  Cusack  some  years  ago,  in  which 
it  was  found  necessary  to  keep  up  the  mercurial  action  for  above 
a  fortnight,  but  in  that  instance  the  disease  had  been  of  much 
longer  standing ;  I  also  treated  a  well-marked  case  in  consultation 
with  Mr.  Mason,  in  which  several  relapses  occurred,  just  as  we 
often  observe  in  syphilitic  iritis. 

Case  No.  4  in  the  Registry  presented  syphilitic  inflammation 
of  the  membrana  tympani  on  both  sides. 

P.  L.,  aged  30,  a  policeman,  with  fair  complexion,  light  hair 
and  eyes ;  has  complained  of  deafness,  unattended  with  pain,  for 
one  month;  says  he  had  a  primary  syphilitic  sore  about  three 
months  ago,  and  lately  suffered  from  sore  throat;  has  slight  copper- 
coloured  patches  upon  the  skin  of  the  forehead,  but  does  not  exhi- 
bit symptoms  of  any  other  eruption.  He  has  ulceration  of  the  soft 
palate,  a  deep  excavation,  with  a  yellowish  ash-coloured  slough 
coating  its  bottom,  existing  on  each  side  of  the  uvula.  He  did  not 
get  mercury  for  the  original  sore.  The  deafness  came  on  in  both 
ears  about  the  same  period,  and  occurred  during  the  daytime. 

Left  Ear. — Meatus  dry,  polished,  of  a  grey  colour,  and  totally 
devoid  of  cerumen.  The  tympanal  membrane  shows  an  exceed- 
ingly well-marked  sub-acute  inflammation ;  there  is  a  pinkish  hue, 
like  that  of  a  rose-leaf,  all  over  it,  but  it  still  preserves  its  polish, 
and  has  not  become  collapsed  or  altered  in  shape:  a  tolerably 
well-marked  crescentic  opacity  margins  its  inferior  attachment. 
The  patient  can  inflate  the  drum,  and  thereby  render  the  vascu- 
larity of  its  external  membrane  more  intense,  and  of  a  darker  red ; 
he  has  a  singing  noise  in  this  ear,  and  only  hears  the  watch  when 
pressed  against  the  auricle. 

Right  Ear. — Meatus  paler,  more  polished  and  opaque  than  on 
the  left  side.  The  tympanal  membrane  is  redder,  and  also  some- 
what collapsed,  so  that  the  malleus  projects  very  prominently. 
Has  an  intermitting  noise  in  character  like  that  experienced  when 
a  conch-shell  is  held  to  the  ear.  Cannot  fully  inflate  the  drum  on 
this  side,  but  the  effort  to  do  so  renders  the  membrane  of  a  deeper 
colour.     Cannot  hear  the  watch  on  this  side. 


A  pill  of  one  grain  of  calomel,  two  of  blue  pilli  and  a  quarter 
of  a  grain  of  opium,  was  ordered  to  be  taken  three  times  a  day. 

30th.  In  this  case  the  mercury  has  acted  fairly  and  legitimately, 
and  we  find  that  the  disease  for  which  it  was  administered  has  al- 
ready given  way.  In  the  right  ear  the  pinkish  colour  of  the  drum- 
head is  very  much  lessened,  the  polish  has  been  in  part  restored, 
and  the  patient  says  that  the  singing  noise  has  greatly  decreased. 
He  now  hears  the  watch  when  applied  to  the  ear.  Upon  the  left 
side  all  the  symptoms  have  improved,  and  the  hearing  distance  has 
increased  about  twcinches.  If  we  apply  the  watch  to  the  ear  and 
then  draw  it  slowly  from  it,  the  deaf  person  will  be  able  to  catch 
the  sound  (the  ear  appearing  to  retain  the  impression  of  the  tick- 
ing) at  a  somewhat  greater  distance  than  if  we  approached  the 
watch  to  the  ear. 

The  mercury  was  lessened  to  one  pill  night  and  morning,  and 
directions  were  given  to  the  patient  to  decrease  it  still  further  if 
the  mouth  became  sorer.  The  ulcers  upon  the  soft  palate,  which 
have  assumed  a  more  healthy  aspect  than  before,  were  brushed 
over  with  a  strong  solution  of  nitrate  of  silver. 

February  1st. — This  patient  is  greatly  improved  in  every 
respect;  hearing  increased  on  both  sides.  Upon  the  left,  the  tym- 
panal membrane  is  much  paler  than  at  the  time  of  the  last  exa- 
mination, and  the  noise  completely  ceased  in  this  ear  upon  the 
previous  day,  without  the  man  being  conscious  of  any  crack  or 
sudden  sound  at  the  time  of  its  cessation.  Upon  the  right  side 
the  membrane  has  improved  in  colour  and  gained  more  polish. 
The  ulcers  in  the  throat  have  thrown  off  their  sloughs,  and  pre- 
sent a  healthy  appearance ;  the  mercurial  action  upon  the  mouth 
is  still  manifest.  The  dose  of  the  mineral  to  be  decreased  to  one 
pill  daily. 

5th.  A  still  further  improvement  has  taken  place  since  last 
report.  Upon  the  right  side  the  membrane  is  yet  slightly  pink- 
ish ;  the  hearing  as  before.  Upon  the  left  side  the  membrane  has 
greatly  improved,  and  is  now  nearly  of  a  natural  colour ;  hearing 
distance  seven  inches ;  throat  healthy ;  mercurial  action  still  ma- 
nifest. Ordered  four  grains  of  hydriodate  of  potash  and  one  drop 
of  tincture  of  iodine,  to  be  taken  in  decoction  of  bark  three  times 


9th.  Grencral  health  and  appearance  much  improved.  Mer- 
curial action  scarcely  perceptible ;  but  the  gums  are  still  slightly 
retracted  beneath  the  lower  incisors,  and  exhibit  a  red,  pulpy  mar- 
gin. The  ulceration  of  the  throat  has  quite  ceased,  and  the  ca- 
vity upon  the  left  side  is  nearly  filled  up.  Ue  says  his  hearing  is 
completely  restored,  but  the  noise  comes  on  occasionally  in  the 
right  ear.  Upon  this  side  there  is  some  secretion  of  cerumen  upon 
the  posterior  surface  of  the  meatus.  The  tympanal  membrane  is 
still  slightly  pinkish,  but  bright,  thin,  and  polished,  reflecting  the 
light  from  its  lower  convex  portion.  He  can  inflate  the  tympanum 
with  facility,  and  upon  applying  the  stethoscope  over  the  meatus, 
while  the  patient  presses  the  air  into  the  ear,  a  slight  gurgling 
noise  can  be  perceived  as  it  reaches  the  cavity  of  the  middle  ear, 
which,  in  all  probability,  contains  a  quantity  of  mucus,  exuded 
from  its  lining  membrane  during  the  inflammatory  process,  which, 
there  can  be  little  doubt,  extended  to  it  and  to  the  lining  of  the 
Eustachian  tube, — parts  that  we  cannot  see, — as  well  as  the  tym- 
panal membrane,  which  we  can  see.  On  the  left  side :  hearing  dis- 
tance ten  inches ;  meatus  still  red,  shining,  and  devoid  of  cerumen ; 
tympanal  membrane  opaque,  but  thin  and  polished ;  a  couple  of 
large  red  vessels  traverse  along  the  insertion  of  the  malleus.  The 
air  does  not  reach  the  cavity  of  the  middle  ear  so  well  as  upon  the 
right,  and  it  has  a  more  squeeling  sound,  probably  arising  from  the 
thickened  membrane  and  the  decreased  caliber  of  the  Eustachian 
tube.  Ordered  to  continue  the  iodide  of  potassium,  and  to  apply 
small  blisters  behind  the  ears  occasionally  for  the  next  fortnight. 

That  Gouty  Otitis  may  exist  I  have  no  doubt,  but  I  myself  have 
never  seen  a  well-marked  example  of  it ;  neither  have  I  yet  read 
a  description  of  that  disease  which  afforded  any  one  pathognomic 
which  could  be  relied  upon.  I  have,  at  page  168,  alluded  to 
attacks  of  gout  in  the  auricle :  Dr.  Graves,  to  whose  authority 
I  there  referred,  gives  an  instance  of  deafness  attended  with 
otorrhoea,  in  which  the  patient's  hearing  was  always  improved 
afler  a  seizure  of  gout  in  the  foot.  Several  continental  authors 
mention  gout  as  a  cause  of  deafness  and  disease  of  the  ear : — Dr. 
Vering  of  Vienna,  in  1832;  Lincke  in  1840;  and  Frank  in  1845  ; 
but  they  are  chiefly  compilers,  whose  writings  on  some  points  re- 

THS  D1AFHB86  OF  OLD  AGE.  267 

mind  one  of  the  variety  of  counts  introduced  into  an  indictment 
in  the  hope  that  some  one  of  them  may  convict  the  prisoner. 
Within  the  last  few  months  a  special  work  has  appeared  on  the 
subject, — that  referred  to  at  pages  49  and  225 ;  but  I  cannot  dis- 
cover in  it  the  requisite  information,  as  the  symptoms  of  the  diffe- 
rent forms  of  gouty  otitis  therein  detailed  are  common  to  every 
other  form  of  aural  inflammation.  The  author,  Mr.  Harvey, 
says  that  "  furuncles  form  and  burst  in  the  muscles*  of  the  ears." 
Next  follows  otorrhoea,  which,  if  of  long  duration,  may  produce 
polypous  growths.  In  frequent  relapses  **  varicose  vessels  become 
develc^d  on  the  membrana  tympani,"  and  when  the  disease  proves 
fatal  from  what  may  be  termed  cerebral  otorrhoea,  '<  all  the  canals 
are  found  to  be  filled  with  purulent  matter,  as  well  also  the  cells 
of  the  mastoid  process,  the  bone  itself  being  in  a  state  of  caries.** 
Now,  when  gout  seizes  upon  the  eye,  it  chiefly  affects  the  sclerotic 
and  the  iris,  and  I  would  expect  from  analogy  that  where  it  was 
seated  in  the  ear,  its  manifestation  would  be  in  the  fibrous  layer 
of  the  membrana  tympani,  in  the  form  of  acute  myringitis,  like 
that  seen  in  rheumatic  cases. 

Some  time  ago  Mr.  Toynbee  published  a  small  tract,  with  the 
attractive  title  of  "  The  Pathology  and  Treatment  of  ^  Deafness 
attendant  upon  old  Age^  in  which  the  author  successfully  combats 
the  conclusion  to  which  medical  men  have  arrived,  that  deafness 
"  depends  upon  a  gradual  and  natural  decay  of  the  powers  of  the 
organ  of  hearing,  and  that  it  must  in  consequence  be  endured  as 
a  disease  entirely  beyond  human  control.**  And  the  result  of  the 
author's  experience  tends  to  show  that  the  decline  of  audition  '^  is 
dependent  upon  the  influences  to  which  aged  persons  are  fre* 
quently  subjected :  namely,  the  prolonged  stay  in  warm  rooms, 
the  avoidance  of  the  open  air,  the  cessation  from  bodily  exercise, 
the  want  of  attention  to  diet,  and  to  the  healthy  performance  of 
the  functions  of  the  skin."  In  support  of  this  view,  Mr.  Toynbee 
has  given  the  dissection  of  eighteen  cases,  a  portion  of  those  al- 
ready enumerated  at  page  110;  and  the  results  obtained  were 
thickening  of  the  mucous  lining  of  the  tympanic  cavity,  and  also 

*  German  vniters  often  style  the  auricle  the  ohrmutchelj  from  its  likeness  to  a  mascle- 
shell  or  conch. 


of  the  membrana  tympani,  with  the  existence  of  bands  of  adhe- 
sion connecting  together  the  various  parts  contained  within  the 
former.  These  evidences  of  previous  inflammation  are,  however, 
but  what  might  be  expected  in  the  post-mortem  examination  of 
any  of  the  mucous  or  serous  cavities  in  aged  persons,  and  the  con- 
dition of  the  ears  in  those  dissections  is  similar  to  what  the  same 
author  has  shown  is  the  chief  cause  of  deafness  in  persons  at  any 
period  of  life. 


I  have  had  some  difficulty  in  determining  whether  to  place 
the  following  disease  among  the  affections  of  the  cavity  of  the 
tympanum  or  the  membrana  tympani,  for,  its  seat  being  in  the 
mucous  layer  of  the  latter  structure,  it  is  manifest  that  it  must, 
sooner  or  later,  spread  over  the  whole  ca vitas  tympani,  and  is 
consequently  common  to  both.  As,  however,  the  visible  signs  of 
the  disease  are  most  apparent  on  the  membrana  tympani,  I  have 
classed  it  along  with  the  affections  of  that  part. 

This  is  a  frequent  affection  in  young  persons,  and,  I  believe,  a 
▼ery  constant  cause  of  deafness  in  after  life.  Its  subjects  are  usu- 
ally from  five  to  fifteen  or  sixteen  years  of  age,  but  it  may  appear 
at  a  much  later  period.  It  chiefly  attacks  the  light-haired,  fair- 
skinned,  blue-eyed,  and  those  who  exhibit  well-marked  evidences 
of  a  scrofulous  constitution.  Its  first  symptom  is  that  of  deafness, 
generally  attributed  to  inattention :  scarcely  a  fortnight  passes  that 
I  do  not  see  a  boy  or  a  girl,  from  ten  to  fifteen  years  of  age,  from 
some  of  the  public  schools,  who,  having  been  deaf  for  two  or  three 
months  previous,  had  been  constantly  reprimanded  for  inattention. 
If  the  relations  are  asked  why  they  did  not  take  advice  for  the 
child  before,  the  general  answer  is,  **  We  thought  it  was  only  a 
cold,  and  would  not  signify." 

The  auditory  passage  is  usually  dry,  but  seldom  red.  The 
tympanal  membrane  will  be  found  of  an  uniform  pinkish  hue,  but 
without  either  thickening  or  opacity,  at  least  in  the  early  stages. 
This  colour,  which  is  somewhat  the  tint  of  pink  blotting-paper, 
appears  to  be  seated  in  the  mi^cous  layer,  and  shines  through  the 
other  laminae  of  the  membrane,  which  still  preserve  their  polish 


and  transparency.  There  is  generally  mucous  engorgement  of 
the  cavity  of  the  tympanum,  with  thickening  and  increased  red- 
ness of  the  faucial  mucous  membrane, — a  condition  which,  there 
can  be  little  doubt,  extends  through  the  lining  of  the  Eustachian 
tube  into  the  middle  ear.  It  is,  generally  speaking,  a  painless  dis- 
ease, and  but  seldom  accompanied  by  tinnitus  in  the  first  instance ; 
occasional  crackling  sensations,  gurglings,  and  loud  reports,  are 
felt  in  the  ear,  and  sometimes  temporary  relief  is  experienced 
therefrom.  Catarrh,  stuffing  in  the  nose  and  frontal  sinus,  and 
great  liability  to  **  cold  in  the  head,"  are  not  unusual  symptoms, 
or  rather  attendants ;  there  is  no  pain  on  pressure  in  or  about  the 
ear,  the  throat,  the  mouth,  br  the  Eustachian  tube.  Strumous 
affections  of  the  eyes  are  not  an  unfrequent  complication,  and 
these,  particularly  corneitis,  which  it  very  much  resembles,  and 
also  strumous  ophthalmia,  sometimes  alternate  with  the  affections 
of  the  ear,  as  shall  be  further  explained  in  this  chapter.  Enlarge- 
ment of  the  tonsils  is  a  very  frequent  accompaniment ;  and  glandu- 
lar swellings  about  the  neck  not  an  uncommon  appearance  in  such 
cases.  The  amount  of  deafness  varies  from  a  hearing  distance  of 
eight  or  ten  inches  to  total  inability  to  hear  a  watch  applied  to 
any  part  of  the  head,  or  held  between  the  teeth,  or  even  to  hear 
what  is  said  in  a  loud  and  distinct  voice ;  and,  generally  speaking, 
the  amount  of  redness  and  vascularity  presented  in  the  membrane 
of  the  drum  is  in  the  ratio  of  the  amount  of  deafness ;  but  the  lat- 
ter is  very  variable,  and  would,  in  many  instances,  appear  to  be 
influenced  by  the  state  of  the  atmosphere, — being  greatest  in  damp, 
moist  weather.  In  some  cases  the  redness  assumes  a  dark,  damask- 
rose  colour,  and  then  we  may  generally  rest  satisfied  that  the 
entire  of  the  middle  ear  is  engaged.  Simple  mucous  discharge 
occurs  occasionally,  and  purulent  otorrhoea  succeeds  in  the  more 
aggravated  cases,  as  the  disease  advances,  but  it  need  not  present 
at  any  period  of  the  affection.  The  constitution  is  generally  be- 
low the  standard  of  health ;  the  patient  is  usually  pale,  languid, 
and  inactive,  with,  perhaps,  slight  loss  of  appetite,  and  some  dry- 
ness of  the  skin. 

This  form  of  myringitis  is  very  liable  both  to  relapses  and  re- 
turns, and  of  this  latter  circumstance  the  patient  or  the  friends 

S70  gTBUMous  mranroiTis. 

Aould  be  always  informed.  When  once  a  child  has  had  this  com- 
plaint, the  slightest  exposure  to  cold  may  re-induce  it. 

The  treatment  in  this  disease  should  be  chiefly  directed  to  im* 
prove  the  condition  of  the  constitudon,  and  I  know  nothing  better 
for  effecting  this  object  than  the  use  of  bark  in  its  various  prepa- 
rations, conjoined  with  iodide  or  bromide  of  potassium,  and,  when 
the  inflammation  is  of  a  more  active  character,  the  bichloride  of 
mercury.  In  the  advanced  stages,  and  where  there  is  much  con- 
stitutional taint  evident,  with  enlargement  of  the  cervical  glands, 
Ac.,  the  oleum  jecoris  will  be  found  most  effectual;  but  whichever 
of  these  may  be  employed,  it  should  be  steadily  persisted  in  for  a 
length  of  time.  This  is  a  slow  and  tedious  disease,  lasting,  even  in 
the  most  favourable  cases,  for  months,  and  being  liable  to  relapse, 
patients  should  be  carefully  watched,  and  their  ears  examined  at 
least  once  a  week,  while  any  trace  of  inflammation  remains.  A 
dry,  pure,  country  air,  and  a  residence  by  the  sea-shore  in  sum- 
mer, will  always  be  found  beneficial ;  but,  as  far  as  my  experience 
extends,  I  have  always  found  bathing  in  the  open  sea  injurious. 
The  warm  bath  occasionally,  appears  to  be  of  use.  As  in  cases  of 
strumous  ophthalmia,  so  in  scrofulous  myringitis,  a  leech  or  two 
may  sometimes  be  required,  although  depletion  is  not  generally 

As  the  tongue  is  usually  white  and  clammy,  and  the  dejections 
of^n  vitiated,  small  doses  of  chalk  and  mercury,  combined  with 
rhubarb  and  columba,  given  as  alteratives  every  second  or  third 
night,  will  assist  our  other  means.  The  diet  should  be  light  and 
highly  nutritious,  while  all  acid  fruits,  pickles,  and  ill-boiled  or 
stale  vegetables,  even  made  dishes  and  pastry,  should  be  avoided. 
Constant  open  air  exercise  during  the  fine  part  of  the  day  is  very 
necessary ;  and  when  the  weather  is  at  all  harsh,  cold,  or  damp,  a 
light  covering  should  be  worn  over  the  ears,  or  small  bits  of  cot- 
ton laid  in  the  conchae ;  but  in  the  house,  or  in  warm  weather, 
these  precautions  are  unnecessary ;  neither  do  I  believe  it  at  all 
efficacious  to  keep  the  head  warmer  than  under  ordinary  circum- 

Counter-irritation  will  be  found  most  effectual,  and  the  vesi- 
cating liniments  more  efficacious  than  the  ordinary  blistering^ 


The  strong  tincture  of  iodine,  acetum  ly ttae,  or  croton  oil  and 
acetic  acid  conjoined  with  spirit  of  turpentine  oil  of  rosemary 
and  soap  liniment,  form  very  useful  applications.  This  latter  lini- 
ment should  be  rubbed  over  the  mastoid  process,  and  lower  down^ 
as  far  as  the  angle  of  the  jaw,  once  or  twice  a  day,  until  a  slight 
vesicular  rash  is  produced,  when  its  use  ought  to  be  discontinued 
until  the  redness  has  disappeared,  when  it  may  be  re-applied  as 
before.  This  irritation  should  be  kept  up  for  a  couple  of  months 
at  least,  varying  the  application  as  the  parts  become  accustomed 
to  any  particular  substance.  Whatever  is  used,  great  care  should 
be  taken  that  it  does  not  spread  over  the  back  of  the  auricle,  which 
is  very  likely  to  become  inflamed  and  greatly  swollen  by  it. 

This  is  one  of  the  diseases  in  which  catheterism  of  the  Eusta- 
chian tube  is  sometimes  necessary,  but,  I  believe,  not  so  often  as 
is  generally  resorted  to.  When  the  patient  himself  can  readily 
pass  a  stream  of  air  into  the  drum,  by  making  a  forced  expiration, 
whilst  we  apply  our  ear,  or  a  stethoscope,  to  his  external  ear,  so 
that  we  can  distinctly  perceive  the  full  and  natural  inflation  of  the 
membrane,  the  introduction  of  a  catheter,  and  the  pressure  of  a 
stream  of  cold  air,  I  believe  to  be  not  only  unnecessary,  but  inju- 
rious. In  cases,  however,  where  mucus  has  collected  in  the  ca- 
vitas  tympani,  catheterism  may  be  resorted  to  occasionally,  and 
even  warm  water,  or  some  bland  fluid,  might  be  thrown  up  by 
means  of  a  syringe,  although  I  have  my  doubts  as  to  the  quantity 
of  any  fluid  which  can  be  thus  driven  into  the  tympanum,  in  order 
to  wash  out  mucus,  pus,  blood,  or  other  extraneous  substances.  As 
I  do  not  believe  that  the  enlarged  tonsils  which  often  accompany 
this  disease — as  they  do  other  strumous  aflections — are  the  cause 
of  the  deafness  and  the  inflammation  manifest  in  the  drum  and 
its  membranes,  I  cannot  recommend  their  removal,  as  has  been 
proposed,  and  acted  on  by  others ;  but  the  application  of  a  strong 
solution  of  nitrate  of  silver  to  the  back  of  the  throat  and  fauces, 
and  particularly  towards  the  mouth  of  the  Eustachian  tube,  by 
means  of  a  piece  of  lint  attached  to  the  end  of  an  aneurism  needle, 
and  applied  as  far  up  as  possible  behind  the  pillars  of  the  soft  pa- 
late, will  be  attended  with  beneficial  results ;  and  the  use  of  astrin- 
gent gargles  should  be  persevered  in  during  the  continuance  of 


the  throat  affection.  If  otorrhoea  ensues,  is  to  be  treated  as  I  have 
recommended  in  the  chapter  upon  that  subject. 

No.  12  in  the  Registry  is  a  case  of  sub-acute  strumous  myrin- 

M.  M.,  aged  16,  a  male. — It  is  quite  manifest,  from  the  way 
in  which  he  speaks,  that  this  boy  has  been  deaf  a  long  time.  His 
utterance  is  indistinct ;  there  is  a  sort  of  whistling  sound  in  his 
speech,  as  if  he  sipped  in  the  air,  and  then  blew  it  out  through  his 
nose ;  his  voice  is  hoarse  and  insonorous,  and  he  labours  under 
that  peculiarity  denominated,  though  incorrectly,  speaking  through 
the  nose ;  the  tonsils  are  not  enlarged ;  the  throat  is  normal,  with 
the  exception  of  a  slight  elongation  of  the  uvula,  but  which  is 
quite  insufficient  to  account  for  the  peculiarity  of  his  speech;  and 
the  nose,  as  far  as  we  can  ascertain,  does  not  exhibit  any  conge- 
nital peculiarity  or  acquired  disease.  This  boy  says  he  has  been 
deaf  since  childhood ;  in  fact,  he  never  remembers  hearing  well ; 
he  has  had  occasional  slight  pains  in  both  ears,  but  they  never 
amounted  to  any  degree  of  intensity;  never  had  a  discharge  from 
either  ear,  but  suffers  from  noise  in  the  left.  His  amount  of  hear- 
ing varies  considerably  from  time  to  time,  and  is  much  decreased 
whenever  he  catches  cold. 

Right  side. — Hearing  distance  three  inches.  Auricle  and  mea- 
tus normal ;  tympanal  membrane  white,  thickened,  opaque,  and 
slightly  collapsed,  or  pressed  inwards  from  its  natural  curvature ; 
its  lower  edge  vascular.  He  cannot  inflate  his  drum ;  but  the  at- 
tempt to  do  so  increases  the  inferior  vascular  crescent,  and  causes 
several  large  red  vessels  to  appear  upon  the  upper  half  of  the  mem- 

Left  side. — Only  hears  on  touching.  Membrana  tympani  ex- 
hibits a  uniform  pinkish  colour,  somewhat  resembling  the  hue  of 
a  rose-leaf;  the  thickening  and  deposit  has  not  yet  taken  place. 
To  introduce  an  instrument  into  the  Eustachian  tube,  and  force 
fluid  or  gaseous  bodies  into  the  middle  ear,  would,  I  believe,  in 
all  such  cases,  be  of  little  avail  until  we  subdue  the  local  inflam- 
mation, and  correct  the  constitutional  tendency  to  its  return.  The 
treatment  consisted  in  slight  local  depletion  frequently  repeated, 
long-continued  counter-irritation  over  the  mastoid  process,  and  the 


exhibitioii  of  such  internal  remedies  as  we  know  by  experiencev 
from  the  diseases  of  analogous  organs,  improve  the  constitutioUi 
and  tend  to  correct  the  tendency  to  disorganizing  inflammation, 
such  as  the  oxymuriate  of  mercury  and  bark,  the  preparations  of 
iodine  and  potassium,  cod-liver  oil,  &c. 


The'following  cases  are  typical  of  a  form  of  strumous  inflam- 
mation of  the  ear  with  which  I  have  been  long  familiar.  It  some* 
times  co-exists  with,  sometimes  alternates  with,  the  ocular  disease* 
What  is  termed  strumous  ophthalmia,  and  also  comeitis,  are  the 
forms  which  the  eye  affection  assumes.  Occasionally  it  is  that  of 
choroido-iritis.  We  often  see  the  patient  labouring  under  the  dis- 
ease of  the  eye  in  the  spring  and  early  summer,  and  that  of  the  ear 
in  autumn  and  winter.  Both  seem  to  be  contingent  on  the  same 
constitutional  diathesis,  but  the  aural  affection  being  generally 
painless,  and  the  part  in  which  it  is  seated  being  concealed  from 
view,  it  attracts  little  attention,  or  it  is  attributed  to  stupidity* 
Unhappily,  in  these  cases  the  mischief  has  been  done:  the  thick- 
ening and  deposit  in  the  membrana  tympani  have  already  taken 
place ;  the  inflammatory  action  has  subsided ;  we  now  only  wit- 
ness its  results,  and  treatment  will  avail  but  little.  Improvement 
of  the  constitutional  health,  and  placing  the  patient  in  the  most 
advantageous  circumstances,  may  possibly  in  time  produce  so  much 
absorption  as  will  give  a  moderate  increase  of  hearing.  I  suppose 
these  cases  belong  to  that  class  which  medical  practitioners,  not 
examining  with  the  speculum,  and,  consequently,  not  knowing 
what  is  going  forward,  were  heretofore  in  the  habit  of  telling  pa- 
tients or  their  friends  *'  to  let  alone,  and  in  time  they  would  grow 
out  of  it.""  If  we  look  into  the  statistics  of  deaf-dumbness  for  dif- 
ferent countries  in  Europe  and  America — and  the  same  remark 
holds  good  with  respect  to  the  investigations  instituted  in  Ireland 
on  the  same  subject — we  shall  find,  among  the  causes  of  acquired 
muteism,  ''diseases  of  the  eyes"  frequently  recorded.  Now,  as  we 
cannot  suppose  that  diseases  of  the  organs  of  vision  could  of  them* 
selves  produce  total  deafness,  leading  to  complete  loss  of  speech, 
we  are  forised  to  the  conclusion,  that  with  the  ophthalmic 



oo«exi8ted  some  insidious  aural^affection  such  as  I  have  described, 
and  so  intense  as  to  produce  dea&ess,  and,  in  very  young  persons^ 
oonsequent  loss  of  speech.  It  generally  occurs  at  from  five  to 
fifteen  years  of  age ;  but,  whether  it  is  owing  to  metastasis  of  the 
morbid  action  from  the  eye  to  the  ear,  or  the  same  strumous  dia« 
thesis  inducing  the  affection  in  the  tympanum,  I  cannot  say. 

No.  26  in  Registry. — H.  M.,  a  female,  aged  16,  with  hazel  eyes, 
jrellowish  hair,  large  projecting  mouth,  freckled  skin,  glandular 
swellings  of  the  neck,  and  other  manifestations  of  struma;  has 
been  deaf  for  several  weeks.  There  is  an  opacity  of  the  cornea 
en  both  sides,  arising  firom  ophthalmia,  for  which  she  was  treated 
at  the  Institution  some  years  ago.  She  had  also  strabismus  of  the 
left  eye,  for  which  she  was  successfully  operated  on  at  twelve 
years  of  age.  Left  side. — Hearing  distance  four  inches;  mem* 
brana  tympani  opaque,  densely  white,  and  collapsed,  a  few  red 
vessels  course  along  the  handle  of  the  malleus ;  tinnitus.  Right 
fide. — Hearing  distance  two  inches ;  membrana  tympani  opaque, 
and  of  a  skim-milk  colour ;  tinnitus.  She  never  suffered  from 
pain ;  never  had  any  discharge  from  either  ear ;  throat  natural ; 
tonsils  not  enlarged.  Ordered  cod-liver  oil,  and  to  have  the  mas- 
toid region  painted  with  strong  tincture  of  iodine  daily. 

No.  27  in  Registry. — A.  S.,  a  female  aged  12,  with  dark  au- 
burn hair,  fair  complexion,  and  hazel  eyes,  suffered  from  pain,  red- 
ness, and  intolerance  of  light  in  both  eyes  some  years  ago ;  traces 
of  the  affection  still  exist  in  the  nebulous  condition  of  both  cornese, 
and  she  bears  the  marks  of  glandular  enlargement;  has  been  deaf 
five  yeai's ;  disease  came  on  with  pain  and  slight  discharge  from 
both  ears;  the  discharge  has  ceased  for  some  time.  Right  side. — 
Meatus  natural;  membrana  tympani  thickened,  opaque,  and  of  a 
brownish  colour,  presenting  the  appearance  of  crumpled  parch- 
ment; hearing  distance  scarcely  half  an  inch.  Left  side. — Mem- 
brana tympani  devoid  of  polish,  and  of  a  brownish-red  hue,  with  a 
crescent-shaped  vascularity  at  its  inferior  edge ;  the  disease  on 
this  side  is  evidently  of  a  more  recent  date ;  hearing  distance  one 
inch.  She  states  that  her  hearing  is  always  better  in  the  spring 
and  summer,  when  the  eyes  are  usually  affected.  Ordered  oxymu- 
liate  of  mercury,  with  bark  and  counter-irritation  behind  the  ears. 

OTITIS  m  coirvBxioii  with  ophthalmxjl  275 

Master  B.,  aged  ten  years  and  a  half,  consulted  me  during  the 
post  month  on  account  of  deafness,  so  complete  as  to  require  the 
use  of  writing  in  communicating  with  him.  He  is  of  a  strumous 
family,  several  members  of  which  have  been  deaf.  He  had  a  bro- 
ther who  lived  to  four  years  of  age,  but  never  exhibited  consoi« 
ousness,  seldom  moved,  never  spoke,  did  not  appear  to  heart 
scarcely  to  see,  and  was  to  all  appearance  idiotic.  Master  B.  had 
convulsions  at  three  months  old,  and  again  when  three  years  of 
age ;  he,  however,  grew  up  to  be  a  stout,  healthy  boy,  intelligent, 
and  with  all  his  faculties  perfect  He  is  well  made,  has  blue  eyes, 
and  rather  light  hair.  In  June,  1851,  he  was  attacked  with  severe 
ophthalmia,  which  lasted  about  six  weeks,  in  the  left  eye.  The 
disease  was  painless,  but  caused  intolerance  of  light,  and  was  cha- 
racterized by  redness  of  the  globe,  lachrymation,  and  great  indis- 
tinctness of  vision.  He  was  then  seized  with  hooping  cough,  and 
after  the  interval  of  a  month  the  right  eye  became  aflfected  simi- 
larly to  that  on  the  left  side.  During  the  winter  his  eyes  got  well, 
with  the  exception  of  an  opacity  on  the  right  cornea ;  and  in 
spring  it  was  remarked  that  his  hearing  had  become  defective, 
and  gradually  lessened  up  to  November  last,  when  it  failed  alto- 
gether. He  cannot  hear  at  all,  even  by  shouting  into  his  left  ear; 
but,  when  his  mother  speaks  to  him,  by  holding  her  mouth  to  the 
right  auricle,  he  is  able  to  distinguish  what  is  said.  His  voice  is 
beginning  to  be  affected ;  it  has  lost  its  intonation,  has  become 
nasal,  and  with  that  sipping  character — as  if  drawn  in  through 
the  closed  teeth — characteristic  of  total  deafness,  which  I  have 
described  at  page  81.  He  is  not  conscious  of  the  ordinary  street 
noises ;  he  does  not  complain  of  tinnitus.  Within  the  last  two 
months  he  has  become  very  nervous,  starting  up  in  his  sleep  with- 
out any  apparent  cause,  especially  if  he  awakes  and  does  not  find 
a  light  in  his  room, — although  this  does  not  seem  to  arise  from  the 
usual  feeling  which  some  children  have  on  that  subject.  Latterly 
some  unsteadiness  of  gait  has  been  remarked ;  and  there  is  a  more 
than  usually  frequent  desire  to  urinate,  especially  aA;er  lying  down. 

The  auricles  are  normal,  as  also  the  external  apertures  of  his 
ears,  although  the  latter  are  dry  and  devoid  of  cerumen.     The 



membraiue  tjmpanorum  nearly  the  same  on  both  sides ;  are  very 
much  altered  from  the  natural  character ;  have  lost  their  transpa* 
rency,  polish,  and  curvature,  being  now  white,  thickened,  opaque, 
and  slightly  collapsed.  There  is  still  some  vascularity  around  the 
tubercle  and  handle  of  the  malleus,  the  result  of  previous  inflam* 
mation,  with  lymphy  deposit  in  the  membrane.  All  that  can  be 
learned  of  the  state  of  the  cavitas  tympani  is,  that  it  is  unsusceptible 
of  inflation  upon  the  right  side,  and  scarcely  admits  any  air  upon 
the  left ;  but  that  the  inflammatory  action,  which  has  left  such  ma- 
nifest traces  in  the  external  membrane,  must  have  extended  over 
the  tympanum,  and  possibly  into  the  labyrinth,  there  can  belittle 
doubt.  From  this  boy's  hereditary  tendency,  his  slight  irregula- 
rity of  gait,  the  nervous  startings  at  night — so  common  to  partially 
deaf  people — and  the  tendency  to  frequent  action  of  the  bladder,  it 
is  not  unlikely  that  his  brain  and  spinal  marrow  may  be  engaged, 
though  in  what  manner  it  is  difficult  to  determine.  The  prog- 
nosis is  not  favourable  to  a  recovery  of  hearing,  yet  it  is  not  alto- 
gether hopeless,  and  the  constitutional  symptoms  may  possibly  be 
grown  out  of  The  treatment  recommended  consisted  in  long- 
continued  counter-irritation  behind  the  ears  and  round  the  nape 
of  the  neck,  with  the  use  of  iodine  in  minute  doses,  taken  in  the 
form  of  a  mineral  water. 

In  cases  of  this  nature,  the  patient  should  be  encouraged  to 
■peak  as  much  as  possible,  and  on  no  account  allowed  to  employ 
signs  or  finger- writing.  He  should  be  spoken  to  in  a  clear,  distinct 
tone  of  voice,  not  too  loud,  and  the  mouth  removed  from  his  ear 
gradually  day  by  day,  so  as,  if  possible,  to  educate  the  sense  and 
increase  the  hearing  distance ;  he  should  also  be  made  to  read 
aloud  every  day.  The  company  of  persons  of  his  own  age  will 
be  advisable,  provided  they  are  not  allowed  to  resort  to  signs  in 
communicating  with  him ;  and  his  mind  should  be  engaged  with 
some  pleasing,  healthful  occupation. 

The  further  treatment — medical,  moral,  and  educational — of 
the  partially  deaf,  either  congenital  or  acquired,  will  be  considered 
in  the  chapter  upon  Deaf-dumbness. 




In  the  otitis  accompanying  scarlaUna^  measleSt  and  amaUrpox^  I 
believe,  as  I  have  already  stated,  that  the  disease  either  commences 
in  the  mucous  lining  of  the  middle  ear,  or  spreads  into  that  cavity 
from  the  mouth  and  fauces  through  the  Eustachian  tube.  Sooner 
or  later,  however,  the  membrana  tympani  becomes  engaged,  and 
is  ruptured  either  by  ulceration  or  from  the  pressure  of  the  con- 
tents  of  the  tympanum,  and  otorrhoea,  with  its  long  and  varied 
train  of  consequences,  ensues.  This  form  of  inflammation  is  there* 
fore  considered  under  the  head  of  diseases  of  the  cavitas  tympani. 
Moreover,  I  am  not  at  present  able  to  state  from  personal  know- 
ledge  what  are  the  peculiarities  of  the  inflammation  which  pre- 
cedes the  discharge  in  those  cases ;  as,  although  of  very  common 
occurrence,  the  practitioner  in  aural  surgery  does  not  in  general 
see  them  till  long  after  their  first  appearance, — seldom,  indeed,  till 
the  disease  becomes  chronic,  and  complicated  with  polypus;  or 
often  not  till  long  after  ulceration  has  destroyed  the  membrane, 
the  ossicula  have  been  discharged,  and  other  irreparable  mischief 
has  occurred.  During  the  severe  epidemic  of  influenza  in  1847, 
I  had  some  opportunities  of  examining  the  membrane  in  the  early 
stage  of  that  aflection,  and  I  found  it  dark-red,  thickened,  and  even 
pulpy,  like  a  highly  injected  portion  of  the  intestinal  mucous  mem- 
brane ;  I  also  observed  in  such  cases  an  increased  and  apparently 
acute  cerumenous  secretion  coating  the  passage. 

The  deafness  aUmding  typhus  fe^yer  is  a  well-known  symptom, 
although  its  true  pathology  has  not  been  yet  elucidated,  because 
a  sufficient  number  of  autopsies  have  not  been  made ;  and  we  have 
not  well- authenticated  descriptions  of  the  appearances  which  the 
parts  susceptible  of  inspection  during  life  present.  In  this  coun- 
try, where  extensive  opportunities  for  studying  typhus  exist,  the 
deafness  which  occurs  during  the  progress  of  fever  is  generally  re- 
garded as  a  favourable  symptom ;  but  I  believe  that  that  which 
arises  in  the  commencement  is  not  so  favourable.  I  can  only 
speak  as  to  the  results.  In  a  few  instances  the  membrana  tym- 
pani was  perfectly  natural,  and  the  tympanic  cavity  free;  and 
the  patients  presenting  such  generally  had  a  bad  form  of  fever, 


with  very  severe  head  symptoms.  Such  cases  I  suppose  to  be 
analogous  to  the  amaurosis  which  sometimes  arises  during  the  pro- 
gress of  fever,  and  often  remains  permanently,  being  a  cerebral* 
and  not  an  ocular,  disease.  But  in  the  great  majority  of  in- 
stances the  membrana  tympani  presented  evidences  of  dideaset 
being  generally  thickened,  opaque,  and  collapsed ;  I  am,  there- 
fore, led  to  believe  that,  in  very  many  cases,  the  dea&ess  oc- 
curring during  the  course  of  a  fever  is  the  result  of  inflam- 
matory action  in  the  ear  itself,  and  not  in  the  brain.  In  this 
opinion  I  am  borne  out  by  the  dissections  of  M.  Passavant,  who 
says,  that  in  *'  patients  cut  off  by  typhus  fever,** — and  he  has  always 
found  certain  pathological  lesions  corresponding  to  the  symptoms 
observed  during  life, — *^  the  petrous  portion  of  the  temporal  bone  is 
congested,  and  the  congestion  extends  to  the  internal  parts,  ex* 
cept  those  of  most  solidity.  The  transparency  of  the  tympanum 
has  disappeared ;  the  membrane  is  thickened,  red,  and  its  epithe- 
lium peels  off  with  great  readiness.  This  injection  of  the  mem- 
brana tympani  extends  some  way  along  the  external  auditory  ca- 
nal, and  in  some  cases  small  spots  of  ecchymosis  are  found  between 
the  injected  vessels.  The  cavity  of  the  tympanum  contains  a 
thick,  viscid  mucus,  which  is  also  found  in  the  Eustachian  tube, 
and  in  the  cells  of  the  mastoid  process.  The  mucous  lining  of  the 
middle  ear  is  congested  likewise,  of  a  rose  or  bluish-red  colour. 
The  labyrinth  does  not  present  any  constant  alteration,  though 
some  points  of  injection  are  occasionally  observed."*  I  have  ob- 
served that  suppurative  otitis  is  not  common  in  typhus,  while  it  is 
the  chief  characteristic  in  the  disease  occurring  during  the  pro- 
gress of  scarlatina  or  measles,  where  the  membrana  tjrmpani  is 
almost  invariably  perforated,  and  a  bad  form  of  otorrhoea  results. 
I  think  it,  therefore,  more  likely  that,  when  local  disease  is  set 
up, — and  from  the  organic  changes  subsequently  observed,  there 
ican  be  no  doubt  of  the  fact, —  the  inflammation  is  seated  in  the 
fibrous  structures,  and  not  the  mucous  lining  of  the  ear.  Typhus 
occurring  in  children  is  a  cause  of  acquired  muteism,  for  which 
see  the  following  chapter,  and  also  that  on  Deaf-dumbness. 

*  Zeitflchrift  fur  Rationalle  Medizin,  quoted  in  The  Medical  Times  for  April  ISth, 
IS^I.    For  fiurtbcr  inCmmuitUMi  aee  the  Mcttoof  on  Otitis  and  Acquired  Muteiim. 



Chronic  inflammation  of  the  membrana  tympani  is  a  very  fre- 
quent cause  of  deafness,  as  may  be  seen  by  referring  to  the  Table 
at  page  102 :  no  less  than  396  cases  out  of  2385,  or  one  in  every 
six,  having  presented  at  the  hospital  in  the  period  specified.  To 
these  might  be  added  the  219  cases  of  thickening  and  opacity  of 
the  membrane,  but  that>  in  a  practical  and  a  therapeutic  point 
of  view,  there  is  a  manifest  difference :  the  former  being  fire<- 
quently  within  the  pale  of  art,  whereas  the  latter,  if  of  long  8tand-> 
ing,  is  generally  irremedial,  and  it  is  more  frequently  accompa- 
nied with  collapse.  In  chronic  myringitis  there  is  generally  some 
evidences  of  inflammatory  action  going  forward.  Whatever  may 
be  the  original  cause  of  the  disease,  it  is  one  that  comes  under  out 
notice  daily ;  and,  although  many  cases  present  as  such  in  the  be** 
ginning  of  the  deafness,  the  appearances  of  chronic  inflammation 
of  the  drum  are  to  be  foimd  as  the  sequelse  of  nearly  all  the  other 
forms  of  inflammation,  in  the  same  way  that  we  find  chronic  oph- 
thalmia so  frequently  a  sequence  of  the  various  acute  forms  of 
inflammation  of  the  eye.  In  external  otorrhoea  the  membrana 
tympani  is  generally  in  this  condition ;  but  there  are  two  other 
special  forms  of  chronic  inflammation  which  may  be  constantly 
observed, — ^the  first,  a  perfectly  painless  deafness ;  the  other  at- 
tended by  paroxysms  of  pain,  ooming  on  at  intervals,  between 
which  the  patient  is  perfectly  free  from  all  uneasiness.  The  lat* 
ter  is  much  more  common  among  females  from  twenty  to  forty^ 
and  is  at  times  accompanied  by  irregularities  of  the  uterine  func- 
tions. The  appearance  of  the  membrana  tympani  is  too  peculiaif 
to  be  mistaken :  it  presents  a  general  thickening  and  opacity,  par^ 
ticularly  of  its  lower  portion ;  besides  which  there  is  almost  invi^ 
riably  a  number  of  spots,  about  the  size  of  pin-heads,  of  greater 
density  than  the  rest,  and  of  a  pearly  lustre,  studded  over  the  sui^ 
face  of  the  membrane.  In  many  cases  it  presents  the  appearance 
of  crumpled  parchment  During  the  quiescent  periods,  we  only 
remark  a  few  straggling  vessels,  carrying  red  blood,  spread  over 
the  surface  of  the  membrane,  and,  for  the  most  part,  coursing  fi*om 
above  downwards,  parallel  with  the  handle  of  the  hammer.  Upon 

280  CHBono  mraiRQiTis. 

any  provocation,  however,  such  as  cold,  or  other  exciting  causes, 
the  membrane  will,  in  a  few  hours,  and  often  without  any  increase 
of  pain,  become  of  an  uniform  dark-red  colour,  precisely  like />an- 
nu8  of  the  cornea,  a  disease  of  which  it  is  the  manifest  analogue. 
The  greater  the  amount  of  thickening  and  opacity,  the  less  will 
be  the  quantity  of  vascularity  and  redness  which  the  membrane  is 
capable  of  assuming,  as  we  perceive  in  cases  of  dense  opacity  of 
the  cornea,  owing,  no  doubt,  to  the  greater  quantity  of  deposit 
obstructing  the  flow  of  red  blood,  by  diminishing,  and,  perhaps, 
also  obliterating,  the  caliber  of  the  vessels.  In  such  cases  the  mem- 
brane is  often  insensible. 

I  have  frequently  seen  a  thin,  skim-milk-coloured  scale  on  the 
membrana  tympani,  like  that  which  mineral  lotions,  lead,  or  alum 
occasionally  leave  on  the  cornea,  with  a  number  of  fine  radiating 
clear  lines  interspersed  through  it,  as  if  the  deposit  had  cracked 
in  these  places. 

Cases  of  this  kind  are  often  of  many  years'  standing,  and  many 
have,  I  am  convinced,  been  treated  as  instances  of  *<  nervous  deaf- 
ness.** The  following  is  no  imaginary  case,  but  one  of  constant 

A  lady,  aged  between  30  and  40,  applies  for  advice.  She  is 
very  deaf,  speaks  in  a  loud,  inharmonious  voice,  and  has  suffered 
from  noise  in  her  ears,  of  all  descriptions,  for  several  years.  She 
usually  prefaces  the  detail  of  her  symptoms  (which  is  generally 
very  long  and  verbose)  by  stating  that  she  does  not  think  much 
can  be  done  for  her,  for  that  she  is  labouring  under  nervous  deaf- 
fies9,  and  is,  therefore,  incurable.  She  has  a  great  objection  either 
to  be  questioned  or  to  have  her  ears  examined  until  she  has  made 
a  full  statement  of  her  case ;  and  as  she  has  had  a  great  variety  of 
opinions,  and  has  used  all  manner  of  remedies,  she  is  tediously  accu- 
rate in  her  account.  She  also  carries  in  her  hand  a  formidable 
Ust  of  questions.  She  states  that  she  has  been  deaf  from  a  very 
early  period ;  that  at  first  her  deafness  was  attributed  to  inatten^ 
tion,  and  endeavoured  to  be  remedied  by  the  means  thought  most 
advisable  by  her  guardians  and  governesses,  and  the  family  doctor ; 
that,  her  disease  increasing,  she  was  brought  to  an  eminent  prac< 
titioner,  who,  after  a  few  casual  inquiries,  but  without  examining 


her  ears,  told  her  Mends  not  to  mind  it,  for  that  she  would  cer- 
tainly '*  grow  out  of  it**  as  she  grew  up,  and  that  probably  all  her 
deafness  would  disappear  about  the  period  of  puberty ;  but  that 
she  might  rub  eau  de  Cologne  on  the  jaw  occasionally  !  With  the 
exception  of  sea-bathing,  and  means  calculated  to  improve  the 
state  of  her  general  health,  no  other  remedies  were  tried,  and  no 
other  advice  sought  for  two  or  three  years;  when,  not  finding  the 
hearing  improved,  but  gradually  becoming  worse,  and  the  tinnitus 
increasing  as  she  grew  up,  a  special  aurist  was  consulted,  who 
stated  the  disease  to  be  entirely  local,  and  curable  by  local  reme- 
dies alone.  During  the  next  few  years,  various  means  were  had 
recourse  to:  catheterism  of  the  Eustachian  tube  was  employed  for 
several  months,  the  tympanum  constantly  washed  out,  and  various 
liquids  and  gases  injected  into  it,  but  without  effect.  Counter- 
irritation  was  next  employed,  with  issues  in  the  arm  and  setons  in 
the  neck,  and  a  long  and  fair  trial  given  to  their  powers.  It  was 
next  proposed  to  remove  the  tonsils,  or,  at  least,  portions  of  them. 
Still  the  disease  progressed.  Drops,  oils, — eel-oil  in  particular,—- 
and  divers  liniments  were  tried  in  vain. 

Broken  down  in  health,  wearied  by  the  variety  of  opinions  and 
the  multiplicity  of  applications,  another  eminent  physician  was 
then  consulted,  who,  having  heard  the  history  of  the  case,  advised 
the  cessation  of  all  local  remedies,  and  recommended  tonics  and 
antispasmodics,  together  with  shower-baths,  change  of  air,  and 
sea-bathing :  stating  at  the  same  time  that  the  disease  was  entirely 
constitutional,  and  of  a  nervous  character.  And  certainly  by  this 
time,  from  hope  deferred, — for  many  specious  promises  of  cure  had 
been  made, — from  the  increase  of  the  tinnitus,  and  from  the  effects 
of  the  long  and  severe  treatment,  the  patient  had  become  remark- 
ably nervous  and  irritable,  brooding  over  her  malady,  and  ren- 
dered unhappy  and  discontented  by  being  imable  to  take  part  in 
any  general  conversation. 

Some  years  now  passed  without  her  doing  anything ;  she  had 
not  become  much  worse,  but  she  certainly  had  not  improved.  Ow- 
ing to  some  new  theory  being  started,  at  the  solicitation  of  friends 
who  had  been  relieved  of  some  curable  form  of  deafness,  or  from 
the  celebrity  of  some  particular  practitioner,  she  was  again  induced 


to  seek  relief;  and  having  arrived  at  the  metropolis,  she  took  the 
round  of  the  doctors  and  aurists.  Some  proposed  perforation  of 
the  drum,  others  recommended  travel;  the  honest  prescribed  no- 
thing ;  the  quack  proffered  his  panacea,  or  offered  to  sell  his  pe* 
culiar  acoustic  instrument,  and  backed  the  recommendation  of  its 
merits  by  the  sign-manual  of  persons  of  rank  and  position.*  The 
homoeopathistSy  hydropathists,  and  mesmerists,  were  each  con- 
sulted, and  the  merits  of  their  systems  tested;  heavy  wet  without, 
and  infinitesimal  nothings  within,  got  every  fair  play ;  and  a  lock  of 
the  lady's  hair  was  sent  to  Paris,  to  a  celebrated  practitioner  in  elec- 
tro-biology ;  the  Spas  of  England  and  the  Badens  of  Germany  were 
visited,  and  their  efficacies  tried ;  electricity,  galvanism,  and  electro- 
magnetism,  were  also  had  recourse  to,  but  ail  in  vain.  The  opinions 
of  those  whom  she  had  consulted  were  as  various  as  the  remedies 
they  employed :  but  the  greater  number  believed  it  to  be  a  constitu- 
tional or  nervous  affection.  Latterly  she  had  been  content  to  look 
out  for  *'  cures*"  among  the  newspaper  advertisements,  and  of  these 
she  possessed  a  large  number  in  her  portfolio. 

Of  several  such  cases,  scarcely  differing  in  a  shade,  I  possess 
the  notes.  In  these  the  following  may  be  gleaned  upon  a  care- 
ful examination.  The  membrana  tympani  is  thickened,  opaque, 
slightly  vascular,  and  sometimes  much  collapsed  or  drawn  in- 
ward towards  the  inner  wall  of  the  tympanum,  so  that  the  han-> 
die  of  the  hammer  forms  a  manifest  projection:  it  has  also  lost 
its  polish  and  become  of  a  dull  pearl-colour.  On  questioning  the 
patient  closely,  it  is  acknowledged  that  attacks  of  ear-ache  were 
suffered  several  years  previously,  particularly  in  winter,  and  that 
such  attacks  were  often  preceded  or  accompanied  by  stuffing  in 
the  nose,  and  symptoms  of  catarrh,  and  were  generally  induced 
by  cold,  to  avoid  which  the  head  was  usually  kept  warmly  muf- 
fled during  such  seasons. 

In  such  a  case  our  art  at  present  does  not  offer  much  hope. 
The  whole  train  of  symptoms  are  evidently  the  result  of  slow 
chronic  inflammation,  affecting,  in  all  probability,  the  lining  of 

*  In  a  window  in  the  Strand,  not  far  from  Somerset  House,  London,  may  be  seen, 
framed  and  glazed,  a  certificate  from  one  of  the  Chief  Justices  of  England,  lauding  and 
noommending,  **  to  all  whom  it  may  conoern,**  a  particnlar  form  of  ear  tnimpet ! 


the  cavity,  as  well  as  the  membrane  of  the  drum,  like  repeated 
attacks  of  choroido^ritis  in  the  eye.  The  only  means  which  can 
with  safety  be  recommended  at  this  period  is  the  application  of  a 
solution  of  lunar  caustic,  applied  with  a  camePs  hair  brush,  every 
third  or  fourth  day,  upon  the  surface  of  the  opaque  membrane, 
while  it  is  fully  exposed  to  view,  and  should  there  be  much  vas- 
cularity present,  the  application  of  a  few  leeches  as  far  in  as  pos* 
sible  round  the  meatus,  at  least  twice  a  week.  In  a  few  cases  the 
arnica  will  assist  to  remove  the  tinnitus  ;  but  it  is  not  so  ef&ca* 
cious  in  this  as  in  more  recent  forms  of  the  affection. 

In  the  cases  of  periodic  pain,  with  a  higher  degree  and  more 
generally  diffused  vascularity,  the  application  of  leeches,  applied 
every  second  or  third  day,  will  be  found  most  efficacious ;  at  the 
same  time  that  the  patient  should  be  brought  under  the  gentle  in* 
fluence  of  mercury,  and  kept  so  for  at  least  a  month.  Under  such 
treatment,  if  the  case  is  not  of  too  long  standing,  the  hearing  will 
often  be  improved,  and  the  symptoms  of  pain  and  tinnitus  re- 
moved. The  membrane  will  clear  somewhat,  but  in  most  cases 
the  spots  of  opacity  remain  indelible.  In  applying  the  solution  of 
nitrate  of  silver  with  a  fine  brush,  or  a  bit  of  cotton- wool  on  the  end 
of  a  probe,  some  caution  and  dexterity  are  required,  as  the  mem- 
brane may  present  a  small  perforation  the  next  day  if  it  has  been 
rubbed  too  hard ;  and  although  I  have  always  seen  such  perfora- 
tions heal  readily,  it  is  an  accident  which  should  be  avoided. 
By  this  application  dark  scales  peel  off  the  surface  of  the  mem- 
brane, and  leave  it  thinner  and  more  transparent  than  before ;  but 
the  moment  it  becomes  inflamed  we  must  desist.  I  knew  two  in- 
stances in  which  the  tinnitus  was  always  relieved  for  several  hours 
or  even  a  day  after  simply  rubbing  the  surface  of  the  membrana 
tympani  with  a  bit  of  moist  cotton. 

There  is  a  form  of  deafness  with  which  I  have  been  long  fa- 
miliar, which  may  be  the  result  of  some  form  of  inflammation.  In 
such  cases,  upon  bringing  the  external  membrane  of  the  drum  into 
view,  we  do  not  observe  any  general  thickening  or  opacity  of  it, 
or  any  apparent  alteration  of  its  texture,  but  a  crescent-shaped 
opacity,  about  a  line  broad  and  three  lines  long,  with  a  tolera- 


bly  defined  edge,  and  rather  rough  upon  its  surface,  occupies 
the  lower  and  usually  the  back  portion  of  ^he  membrane.  It 
is  generally  more  insensible  than  the  rest  of  the  membrane,  and 
differs  from  the  ordinary  opacity,  in  the  surrounding  structure 
being  apparently  free  from  disease,  in  its  almost  invariable  seat, 
its  well-defined  edge,  and  in  its  having  a  portion  of  unaffected 
membrane  between  it  and  the  bony  attachment  of  the  membrana 
tympani.  By  a  very  slow  and  gradual  process  this  disease  spreads 
over  the  greater  portion  of  the  membrane,  and  produces  porma* 
nent  deafness.     I  am  not  aware  of  any  remedy  for  it. 

In  some  instances  I  have  observed  a  manifest  granular  state  of 
the  membrane,  not  unlike  the  surface  of  a  half-ripe  raspberry,  the 
intervening  portions  between  the  reddish  elevations  being  thick- 
ened and  opaque ;  it  is  unattended  by  discharge.  In  these  cases  I 
have  procured  an  uniform  thinning  and  clearing  of  the  membrane, 
by  the  occasional  application  of  a  fine  point  of  nitrate  of  silver; 
but  this  requires  very  great  care,  and  should  be  persevered  in  for 
a  great  length  of  time,  at  least  two  months ;  it  should,  if  possible,  be 
applied  so  lightly  as  not  to  induce  a  discharge.  Many  of  those 
cases  are  the  result  of  long-continued  otorrhoea,  but  which,  hay* 
ing  healed,  has  left  the  membrane  in  this  condition. 

Many  females  have  become  deafimmediately  after  parturition. 
In  such  cases  I  have  generally  observed  a  speckled  opacity  of  the 

No.  9  in  the  Registry  is  a  case  of  thickening  and  opacity  of 
the  membrana  tympani. 

A.  H.,  a  female,  aged  30:  complains  of  deafness,  tinnitus  an- 
num, and  constant  pain  in  her  right  ear,  and  partially  in  the  left* 
Greneral  health  impaired,  she  says,  on  account  of  her  aural  affection ; 
the  almost  incessant  hammering  noise,  and  the  pain — aggravated 
whenever  she  gets  cold — rendering  her  very  miserable  and  ner- 
vous. The  membrana  tympani  upon  the  right  side  is  of  a  pearl  co- 
lour, and  evidently  thickened  by  some  interstitial  deposit ;  it  has  lost 
its  polish,  but  retains  its  natural  position,  and  the  patient  can  press 
it  outward  by  inflating  the  drum.  Posteriorly,  there  is  a  well-de- 
fined streak  of  dense  white  opacity  proceeding  downwards  and 


outwards  from  the  point  of  the  malleus.  Hearing  distance  three 
inches.  Left  side  nearly  natural ;  hearing  distance  twelve  inches. 
Scarelj  ever  feels  any  pain  unless  when  much  exposed  to  cold. 


Thickening  and  opacity  of  the  membrana  tyrapani,  with  or 
without  flattening,  collapse,  or  drawing  inwards  towards  the  cavity 
of  the  tympanum,  is  the  most  frequent  apparent  result  of  each  and 
all  of  the  foregoing  varieties  of  inflammation  in  that  structure.  If 
we  examine  into  the  sequelse  of  ophthalmic  inflammation,  we  find 
that  opacity  either  of  the  cornea  or  lens  is,  in  a  great  majority  of 
those  instances  in  which  the  organ  has  not  been  totally  destroyed, 
the  chief  cause  of  loss  of  vision.  Lymph  efiused  upon  either  side 
of  the  membrana  tympani  or  between  its  laminae  is  the  manifest 
consequence  of  most  inflammations,  in  addition  to  which  the  ex- 
temal  cuticular  layer  may  be  thickened  from  pressure,  as  already 
explained  at  page  188,  or  by  extension  of  cutaneous  diseases,  as 
shown  at  page  198  ;  and  within,  the  increased  vascularity  and 
hypertrophy  of  the  mucous  lining  of  the  tympanic  cavity  over  the 
posterior  surface  of  the  membrana  tympani  naturally  gives  rise  to 
permanent  thickening  of  this  structure.  An  examination  of  the 
Registry  of  200  cases  in  the  previous  part  of  this  work,  and  the 
analysis  of  that  Registry,  at  page  136,  will  explain  the  various 
conditions  of  the  membrane  to  which  I  have  so  frequently  alluded. 
It  is  possible  that  in  those  cases  where  we  observe  clear,  pocket- 
like projections  in  the  surrounding  opaque  membrane,  that  either 
from  rupture,  ulcer,  or  an  outspreading  of  the  fibres  of  the  true  cen- 
tral laminae,  that  there  is  a  partial  deficiency  of  the  membrane  at 
these  spots ;  but  we  require  minute  pathological  investigation  to  de- 
termine which  particular  structure  is  deficient.  It  is,  however,  very 
probable  that  these  projections  are  formed  by  the  mucous  mem- 
brane bulging  through,  and  the  dermoid  layer  being  pressed  out- 
wards, like  what  takes  place  in  a  sacculated  bladder,  occasionally 
in  the  iris,  and  often  in  the  cornea. 

Atheromatous  or  calcareous  deposits  form  between  the  laminae 
of  the  membrana  tympani,  and  generally  occur  in  middle-aged  fe- 
males.    The  deposit  is  usually  seated  in  the  anterior  vibrating 


portion,  is  of  a  yellowish  colour,  and  has  a  sharp,  well-defined 
but  irregular  edge,  totally  different  from  that  of  a  lymphy  exuda- 
tion, which  generally  shades  off  into  the  surrounding  membrane. 
If  scratched  with  a  cataract  needle,  it  will  be  found  giitty,  but  what 
its  exact  composition  is  I  cannot  tell.  I  believe  I  was  the  first  to 
notice  this  peculiar  appearance,  ten  years  ago,  in  my  essay  upon 
Otorrhosa,  where  I  then  stated,  at  page  38,  ''  I  have  in  three  in- 
stances seen  earthy  deposits  between  the  layers  of  the  membrane 
like  those  which  are  found  in  the  heart  and  arteries  and  cornea; 
ihey  were  regular  in  shape,  occupied  about  one  half  of  the  tense 
portion  of  the  membrane,  and  afforded  a  gritty  feel  when  touched 
with  a  sharp  instrument.  In  each  case,  severe  deafness  existed  in 
that  ear.  In  one  of  these  cases,  that  of  Lady  B.,  I  pointed  out 
this  peculiar  morbid  deposit  to  Sir  H.  Marsh,  about  eight  months 
ago""  (1843).  Four  such  cases  are  noticed  in  the  Registry  (see 
page  137),  and  I  have  also  seen  several  others  in  private  prac- 
tice. Sensibility  remains  in  these.  I  believe  the  disease  to  be 

Thickening  and  opacity  of  the  membrane  is  as  difficult  of  cure 
as  the  same  appearance  in  the  cornea.  Much  must  depend  upon 
the  age  of  the  patient,  who  may  outgrow  it ;  upon  the  state  of  the 
general  health,  from  the  removal  of  the  opacity,  being  a  process  of 
absorption ;  and  also  upon  the  length  of  time  which  has  elapsed 
since  the  original  inflammation  existed.  The  diagnosis  should 
always  be  guarded :  if  redness  and  vascularity  still  linger  about 
the  membrana  tympani  and  external  meatus,  we  may  entertain  a 
hope  of  improving  the  patient's  condition  by  the  means  pointed 
out  for  treating  chronic  inflammation  in  the  foregoing  section,  and 
the  employment  of  such  constitutional  and  dietetic  measures  as 
serve  to  correct  or  alter  the  exciting  cause.  But  if  the  patient  has 
passed  thirty  years  of  age;  if  all  vascularity  has  been  removed;  if 
the  meatus  is  dry,  scaly,  and  totally  devoid  of  cerumen,  and  that 
the  membrana  tympani  presents  upon  its  external  surface  a  uni- 
form sheet  of  pearlaceous  whiteness,  with  perhaps  one  or  two  su- 
perficial red  vessels  coursing  along  the  malleus,  treatment  does 
not  hold  out  a  hopeful  chance  of  success.  We  see  enough  of  ma- 
nifest disease  to  account  for  the  deafness,  but  we  cannot  tell  in 


what  condition  the  membrane  lining  the  tympanic  cavity  may  be ; 
what  amount  of  opacity  and  thickening  may  have  taken  place  in 
the  membrane  of  the  fenestra  rotunda ;  whether  anchylosis  of  the 
stapes  to  the  fenestra  ovalis  exists ;  or  whether  bands  of  adhesion 
have  formed  between  the  membrana  tympani  or  the  ossicula  and 
neighbouring  parts.  Even  supposing  that  none  of  these  patholo- 
gical changes  have  happened,  and  that  the  disease  simply  consists 
in  an  opacity  of  the  membrana  tympani,  and  that  the  patient  is  in 
good  health,  and  absorption  going  forward,  a  year  and  more  must 
occur  before  we  can  expect  the  membrane  to  clear,  either  in  whole 
or  in  part,  and  few  persons  will  be  found  with  sufEcient  confidence 
and  patience  to  carry  out  the  prescribed  treatment;  yet  I  have 
sometimes  been  astonished  at  the  favourable  turn  which  some  of 
the  most  unpromising  cases  have  taken,  in  the  instance  of  per- 
sons who,  like  the  woman  in  Scripture,  prevailed  through  their  im- 
portunity, even  after  I  had  given  a  most  unfavourable  prognosis. 
The  treatment,  like  that  of  chronic  inflammation,  consists  in 
painting  over  the  surface  of  the  membrane  with  a  solution  of 
nitrite  of  silver,  of  from  ten  to  twenty  grains  to  the  ounce,  about 
twice  a  week.  A  cameFs  hair  pencil  is  not  so  good  a  means  of  ap* 
plying  it  as  a  bit  of  cotton- wool  twisted  round  the  end  of  a  probe, 
as  it  should  not  merely  be  applied,  but  rubbed  over  the  membrane, 
which  in  such  cases  is  almost  insensible,  and  after  a  few  applica- 
tions will  become  blackened  in  patches,  showing  the  usual  efiect 
of  lunar  caustic  on  dermoid  structures.  We  must  then  desist  until 
these  dark  scales  peel  off,  and  when  they  do,  we  should  continue 
the  application.  Should,  however,  the  membrane  become  vascu- 
lar or  inflamed  during  the  process,  the  use  of  the  caustic  must  be 
omitted  until  the  parts  become  quiescent.  The  patient,  if  intelli- 
gent and  careful,  may  be  taught  to  apply  the  caustic,  but  the  parts 
should  be  inspected  at  least  once  a  fortnight.  Under  this  plan  of 
treatment  I  have  succeeded  in  thinning  the  membrane  and  restor- 
ing hearing  in  most  unpromising  cases,  whereas  in  others  I  have 
utterly  failed.  I  have  tried  iodine  and  other  substances,  but  have 
not  succeeded  with  any  so  well  as  the  nitrate  of  silver.  Counter- 
irritation  should  at  the  same  time  be  kept  up  over  the  mastoid 



Collapse,  or  falling  inwards,  of  the  membrana  tjmpani,  towaid 
the  middle  ear,  is  a  very  constant  appearance  observed  in  making 
aural  examinations,  as  already  remarked  in  the  Analyns  of  the 
Registry  at  page  138,  where  this  peculiar  affection  is  described.  I 
have  remarked  two  forms  of  this  peculiarity.  In  one  the  mem- 
brane  is  thickened,  opaque,  and  exhibits  all  the  evidenoes  of 
previous  inflammation ;  in  the  other,  its  texture  is  unaltered,  it 
has  merely  become  pressed  inward  towards  the  cavitas  tympani, 
leaving  the  tubercle  and  handle  of  the  malleus  projecting  out- 
wards in  strong  relief.  The  former  is  always  accompanied  by 
severe  deafness ;  with  the  latter  form  need  only  be  associated  tin- 
nitus, although  deafness  often  accompanies  it.  Cleland  was  aware 
of  this  peculiar  condition  of  the  membrana  tympani  more  than 
one  hundred  years  ago,  as  I  have  shown  at  page  14  of  this  work, 
to  which  passage  I  would  here  refer  the  reader.  Several  old 
authors  have  written  upon  a  disease  which  they  call  relaxation  of 
the  membrana  tympani, — Willis,  Joseph  Frank,  and  others,  sup- 
posing that,  when  it  was  relaxed,  it  fell  inwards,  while  Beck  con- 
ceived that  it  pressed  out  towards  the  external  auditory  passage, 
which,  I  believe,  only  occurs  from  accumulations  in  the  tympanum. 
Were  we  to  rely  upon  authorities  and  not  upon  observations  and 
facts,  we  might  still  look  upon  the  question  as  undecided ;  but  that 
the  membrane  is,  from  some  cause  or  other,  frequently  rendered 
more  concave  than  natural  and  pressed  inwards  toward  the  tympa* 
num,  does  not  admit  of  a  doubt.  Kramer,  in  his  criticism  of  Willis, 
adduces  as  insupportable  the  assertion  of  some  forms  of  deafness 
being  improved  by  loud  noises  occurring  in  the  vicinity, — as,  for 
instance,  while  a  drum  was  beaten  in  a  room,  and  *'  that  an  indi- 
vidual, whose  hearing  was  defective,  heard  everything  during  the 
ringing  of  a  peal  of  belb."*  Yet,  it  is  a  well-established  fact,  that 
certain  deaf  individuals  will  be  able  to  hear  the  human  voice  in 
its  ordinary  tones,  and  to  enter  into  conversation  while  travelling 
in  a  carriage,  walking  in  a  street  through  which  vehicles  are  pass- 
ing, or  under  any  circumstance  in  which  the  air  is  agitated  by 
noises  much  louder  than  those  in  which  the  conversation  they  are 


listening  to  are  addressed.  Thus,  I  knew  an  instance  of  a  miller 
who  could  hear  perfectly  well  ordinary  conversation  while  stand- 
ing within  the  working  mill,  but  so  soon  as  the  mill  ceased,  or 
that  he  removed  into  another  locality,  he  could  only  hear  when 
spoken  to  in  a  much  louder  tone  of  voice.  This  peculiar  symp- 
tom,  a  satisfactory  explanation  for  which  has  not  yet  been  given, 
has  generally  been  enumerated  as  one  of  the  characteristics  of  true 
nervoua  deafness.  Thus,  Kramer  himself,  when  describing  his 
*'  erethitic  form  of  nervous  deafness,**  says,  notwithstanding  his  pre- 
vious criticism  of  Willis,  that,  '*  if  the  patient  sit  in  a  cart  which 
is  rattling  quickly  over  a  stone  pavement,  or  presses  his  forehead 
against  the  frame  of  a  window  whilst  a  waggon  is  rattling  past, 
so  that  the  whole  house  is  shaken  by  it ;  or  if  a  peal  of  bells  be 
ringing  near  the  patient,  or  a  drum  be  beaten,  the  auditory  nerve 
becomes  so  excUed  by  those  deep-toned  uniform  noises  that,  whilst 
they  continue,  the  patient  often  hears  the  human  voice  better  than 
a  sound  person  whose  ear  is  stunned  by  the  noise.**  The  facts  are 
certainly  as  thus  stated,  but  the  inference  does  not  follow.  We 
have  no  authority  for  believing,  neither  are  there  any  known  phy- 
siological circumstances  to  warrant,  the  assertion,  that  the  audi- 
tory nerve  becomes  thus  excited ;  or,  if  excited  by  grave  tones, 
that  it  is  at  that  moment  more  capable  of  appreciating  sharp  or 
acute  tones.  This  peculiar  phenomenon  has  always  appeared  to  me 
more  explicable  by  a  consideration  of  the  state  of  tne  membrana 
tympani,  and  it  is  remarkable  that  it  does  not  occur  in  cases  where 
that  structure  has  been  in  whole  or  in  part  removed.  Cleland,  as  I 
have  already  remarked,  believed  that  the  altered  position  of  the 
membrana  tympani  was  caused  by  '^  a  violent  clap  of  thunder, 
noise  of  cannon,  or  the  like.**  I  do  not  remember  having  met  with 
an  instance  arising  from  the  former  cause ;  but  it  is  not  improba- 
ble, that  some  of  the  cases  of  deafness  which  commonly  occur 
among  the  artillery  may  be  owing  to  a  collapse  of  the  membrana 

The  cause  of  collapse  some  writers  have  endeavoured  to  ex- 
plain, by  supposing  that  the  tensor  tympani  muscle  had  snapped, 
or  that  the  ossicula  and  mechanical  apparatus  of  the  middle  ear 
had  become  deranged ;  but,  from  the  fact  that,  in  all  cases  of  col- 



lapee,  the  handle  of  the  malleus  is  not  drawn  inwards  along 
the  membrane  on  each  side  of  it,  I  am  not  inclined  to  entertain 
that  opinion.  I  believe  the  collapse  may,  in  most  instances,  be  attri- 
butable to  one  or  other  of  two  causes, — partial  or  complete  closure 
of  the  Eustachian  tube,  by  which  means  the  pressure  of  the  exter- 
nal atmosphere  must  of  necessity  drive  the  membrane  inwarda; 
and  inflammation  of  the  cavity  of  the  tympanum,  when  adhesive 
bands  have  formed  between  the  internal  surface  of  the  membrane 
and  the  neighbouring  parts,  which,  as  shown  by  the  dissections  of 
Mr.  Toynbee  at  page  111,  appeared  in  as  many  as  179  itny^||^«>f^ 
out  of  915  examinations. 

This  IS  a  cause  of  deafness  most  difficult  to  treat ;  but,  unless 
some  other  disease  coexist  with  it,  we  may  generally  assure  the 
patient  that  the  deafness  will  not  increase.  When  once  the  mem- 
brane has  been  pressed  for  any  length  of  time  inwards,  it  is  very 
difficult  to  restore  its  position  permanently.  Many  persons  inflate 
the  drum,  by  holding  the  nose  and  making  a  forced  expiration 
whenever  they  wish  to  hear  what  is  said.  In  others  we  can  tem- 
porarily restore  the  natural  position  by  Eustachian  catheterism ; 
but  in  both  the  membrane  returns  to  its  former  condition  in  a  sh<^ 
time.  I  have  tried  the  effect  of  exhausting  the  air  in  the  ezter> 
nal  meatus  by  means  of  a  syringe  accurately  adjusted  to  the  outer 
aperture ;  but  I  have  not  effected  any  good  thereby.  On  the  con- 
trary, I  think  the  congestion  produced  by  the  exhaustion  is  rather 
detrimental  to  the  organ.  I  have  frequently  afforded  temporary 
relief  by  dropping  with  a  glass  tube  a  little  nitrous  ether  into  the 
meatus,  and  immediately  stopping  the  external  aperture  either 
with  the  finger  or  by  pressing  the  tragus  over  it.  Some  slight 
pain  is  instantaneously  felt,  followed  by  a  boiling  sensation,  then  a 
glow  of  heat,  and  a  feeling,  to  use  the  patient^s  expression,  as  '^if 
the  drum  of  the  ear  was  sucked  out"  It  is  difficult  to  understand 
how  this  remedy  acts,  and  assists  to  restore  the  membrane  to  its 
normal  position. 

The  following  case.  No.  15  in  the  Registry,  showing  thicken- 
ing and  collapse  of  the  membrana  tympani  on  both  sides,  is  highly 
characteristic  of  the  affections  described  in  the  three  foregoing 


M.  K.,  a  married  female,  aged  46,  has  suffered  from  deafness 
accompanied  by  noise  in  her  ears,  occasional  headachs,  and  gene- 
ral nervousness,  for  the  last  ten  years.  Cannot  hear  the  ticking  of 
the  watch,  though  pressed  against  the  ears,  on  either  side.  Her 
disease  crept  on  gradually ;  is  made  worse  on  catching  cold.  She 
has  not  experienced  pain  in  the  ears,  and  has  no  hereditary  ten- 
dency to  deafness.  The  tongue  is  clean ;  throat  normal ;  pulse 
natural ;  digestive  functions  healthy ;  the  voice,  however,  is  harsh, 
husky,  and  inharmonious,  showing  that  she  has  been  deaf  a  long 

What  have  we  learned  from  the  subjective  symptoms  just  de- 
tailed of  the  actual  cause,  proximate  or  remote,  of  the  deafness  in 
this  case  ?  Absolutely  nothing.  Its  early  history  is  obscure,  and 
the  symptoms  described  are  common  to  many  affections  of  the  ear. 
By  her  ordinary  medical  attendant,  if  she  was  in  a  rank  of  life  to 
have  one,  her  disease  would  be  set  down  as  a  case  of  '*  nervous 
deafness,**  because  it  has  been  of  such  long  standing,  has  resisted 
or  is  now  unamenable  to  treatment,  and  because  this  poor  woman 
has,  from  her  loss  of  hearing,  and  the  noise  in  her  ears,  become 
*'  so  nervous.**  Her  treatment,  she  says,  has  consisted  in  being 
syringed  by  a  doctor,  who,  finding  the  remedy  ineffectual,  then 
recommended  her  **  not  to  be  quacking,  lest  she  might  lose  the 
little  hearing  she  had ;"  in  pouring  "  drops,**  which  she  saw  adver- 
tised in  a  newspaper,  into  her  ears  every  night  for  three  weeks ; 
in  using  '*  brandy  and  salt,**  which  a  charitable  lady  recommended 
to  her  as  an  infallible  remedy  when  that  nostrum  was  in  vogue ; 
in  inserting  a  ''  piece  of  rusty  bacon**  into  her  ears  at  the  sugges- 
tion of  an  *'  old  woman  ;**  in  applying  glycerine,  because  she 
heard  it  could  do  no  barm  ;  and,  lastly,  in  having  tobacco-smoke 
blown  into  her  ears  by  a  '*  travelling  aurist,**  which  caused  her  to 
faint,  and  rendered  her  weak  and  debilitated  for  several  days  after. 
Since  then,  having  lost  confidence  in  treatment,  she  has  not  ven- 
tured to  seek  relief. 

Let  us  now  see  what  is  the  state  of  the  affected  organ.  The 
appearances  are  nearly  the  same  on  both  sides ;  the  meatus  is  ra- 
ther smaller  than  natural,  dry,  vascular,  and  totally  devoid  of  ce- 
rumen ;  the  membrana  tympani  is  thickened,  white,  and  greatly 



ooUapsedy  so  that  the  tubercle  and  handle  of  the  malleus,  to  which 
it  is  attached,  stand  out  much  more  prominently  than  they  ought. 
Owing  to  the  irritation  produced  by  the  insertion  of  the  speculum, 
several  red  vessels  have  begun  to  appear  upon  the  tympanal  mem- 
brane, particularly  along  the  site  of  the  malleus.  These  are  not 
the  appearances  of  present  inflammation,  but  are  the  result  of  the 
enlargement  of  the  vessels,  caused  by  long-continued  previous  in- 
flammatory action  ;  and  they  are  now  rendered  apparent  by  the 
slightest  irritation.  We  constantly  observe  the  same  phenomenon 
in  an  eye  which  has  recently  sufiered  from  internal  ophthalmia. 
The  conjunctiva  and  sclerotica  may  be,  to  all  appearance,  natural ; 
but,  upon  rubbing  the  globe  with  the  lid,  or  subjecting  it  to  any 
other  exciting  process,  we  reproduce  the  well-marked  pinkish  zone 
round  the  cornea  which  characterizes  inflammations  of  the  inter- 
nal tunics.  This  patient  has  not  suffered  pain  in  the  ears,  and  the 
absence  of  this  symptom  is  often  brought  up  by  medical  men  in 
proof  of  the  non-inflammatory  nature  of  the  disease ;  but  we  all 
know  now,  that  sub-acute  inflammation  may  exist  in  other  organs 
of  the  body, — in  the  lungs,  the  eye,  the  liver,  and  the  mucous  and 
serous  membranes, — without  the  patient  being  sensible  of  pain. 
She  cannot  fully  inflate  the  drum,  but  she  can  raise  up  the  tympa« 
nal  membrane  a  little — a  proof  that  the  Eustachian  tube  is  free — 
and  also  render  it  more  vascular.  The  inflammatory  process  has, 
in  all  likelihood,  not  been  confined  to  the  external  membrane  of 
the  tympanum,  but  has  spread  over  the  mucous  lining  of  that  ca- 
vity ;  and  it  is  more  than  probable  that  bands  of  adhesion  exist  in 
the  middle  ear,  similar  to  those  which  dissection  occasionally  shows 
us  between  the  pleura  pulmonalis  and  pleura  costalis,  between  the 
various  reflections  of  the  peritoneum,  or  between  the  back  or  pu- 
pillary edge  of  the  iris  and  the  anterior  capsule  of  the  lens. 

As  the  amount  of  apparent  disease,  and  the  morbid  changes 
which  are  manifest  in  this  case,  are  insufficient  to  account  for  the 
great  loss  of  hearing,  we  must  attribute  the  defect  to  an  extension 
of  the  inflammation  from  the  middle  into  the  external  ear,  affect- 
ing the  vestibule  and  labyrinth,  and  possibly  thickening  or  ren- 
dering invibratile  the  membrane  of  the  fenestra  rotunda.  Ana- 
logy with  the  pathology  of  the  eye  here  again  assists  us.  In  many 


instances  of  internal  ophthalmia  do  we  not  observe  similar  pheno* 
mena,  where  the  amount  of  mischief  done  to  the  sensitive  appa« 
ratus  is  not  commensurate  with  the  evidence  of  disease  in  the 
external  mechanism,  and  the  more  delicate  the  organization,  the 
less  is  the  morbid  product  apparent  ?  This  woman's  chief  com- 
plaint is  of  the  noise  in  her  ears,  which  is  so  distressing  that  it  dis- 
turbs her  sleep,  affects  her  mind,  and  prevents  her  following,  with 
any  degree  of  energy  or  interest,  the  ordinary  occupations  of  life. 
Treatment  holds  out  but  little  hope  of  amendment  in  such  a 
case  as  this,  which  is  one  of  very  common  occurrence  indeed,  in 
this  country.  The  strong  solution  of  nitrate  of  silver  applied  upon 
the  thickened  membrane  may  produce  some  alleviation,  particu- 
larly of  the  tinnitus ;  but,  from  the  amount  of  collapse,  it  did  not 
present  a  sufficient  warrant  to  attempt  relief  by  perforation.  It  is 
manifest  that,  when  the  membrana  tympani  is  thus  collapsed  and 
bound  down,  it  ceases  to  vibrate  on  the  impingement  of  sound. 


This  seems  the  proper  place  to  consider  the  propriety  of  per- 
forating the  membrana  tympani,  the  cases  to  which  it  is  applica- 
ble, and  the  best  mode  of  performing  it.  Closure  of  the  Eusta- 
chian tube,  accumulation  of  extraneous  matter  within  the  tympa- 
num, and  the  thickened  condition  of  the  membrana  tympani  pre- 
viously described,  are  the  circumstances  which  writers  seem  to 
think  demand  it.  I  do  not  believe  it  to  be  either  required  or 
applicable  in  the  first  class  of  cases ;  but  that  subject  will  be  con- 
sidered more  at  length  in  the  chapter  upon  Diseases  of  the  Eus- 
tachian tube.  When  we  are  convinced  that  the  cavity  of  the 
tympanum  is  filled  with  uncoagulated  blood,  and  that  it  cannot 
find  exit  through  the  Eustachian  tube,  an  aperture  may  be  made 
in  the  membrane  to  give  it  vent ;  but  such  an  aperture,  being  in- 
tended to  close  after  it  has  performed  its  office,  is  widely  different 
from  perforation  made  by  cutting  out  a  portion  of  that  structure 
for  the  purpose  of  assisting  hearing.  To  relate  the  whole  history 
of  the  operation  for  perforation,  the  cures  said  to  have  been 
achieved  by  it,  the  various  ingenious  instruments  invented  for 
performing  it,  and  the  number  of  essays  written  by  distinguished 

294  PBRFoaATioH  or  thb  membbaha  ttmpavi. 

men  upon  the  subject,  would  occupy  more  space  than  it  is  worth 
in  a  practical  work  of  this  description — more  particularly  as  the 
operation  has  fallen  into  disuse  of  late,  Eustachian  catheterism 
having  in  part  superseded  it,  and  several  of  the  so-called  cures  not 
having  stood  the  test  of  time  and  close  investigation,  so  that  no 
well-authenticated  recoveries  by  the  operation  have  been  related 
for  several  years  past. 

To  Sir  Astley  Cooper  has  been  awarded  the  merit  of  first  In- 
troducing the  operation :  he  performed  it  with  a  small  troehar, 
but  the  aperture  made  therewith  was  soon  found  to  close.  There 
has  not  been,  perhaps,  in  the  whole  history  of  medicine  during  the 
present  century  a  discovery  to  which  so  much  praise  was  at  the 
time  awarded,  that  subsequent  investigation  and  experience  have, 
to  say  the  least  of  it,  so  much  disparaged.     In  the  first  place,  the 
celebrated  author  was  not,  as  I  have  shown  at  page  15,  the  origi- 
nal inventor  of  the  operation ;  although  I  feel  convinced  he  was 
unacquainted  with  Degravers*  cases,  but  the  fault  lay  vrith  those 
who,  perhaps,  too  rapidly,  and  without  sufficient  examination, 
awarded  honours  well  due  to  the  man,  but  undeserving  the  sub- 
ject.    Itard  tried  the  operation  in  a  great  number  of  instances, 
but  without  any  determined  beneficial  result.     Kramer,  whose 
work  contains  a  very  just  review  of  the  operation  and  the  authors 
who  have  supported  it,  states,  *'  that  the  thickening  of  this  mem- 
brane, unaccompanied  by  any  other  disease  of  the  ear,  invariably 
affords  the  only  true  indication  for  its  perforation."     Himly  in- 
vented an  instrument  which  obviated  the  closure  made  by  the 
simple  puncture  of  the  trochar,  or  any  other  piercing  instrument, 
and  this  has  been  further  modified  by  Fabrizzi  and  others.     The 
very  ingenious  instrument  of  the  latter  consists  in  a  fine,  round 
stem,  four  inches  long,  fashioned  at  the  end  into  a  small  corkscrew 
point,  and  enclosed  within  a  canula  working  next  the  handle  on 
a  nut,  and  furnished  at  the  point  with  a  sharp  steel  cutting  edge. 
When  the  punch  or  canula  is  screwed  home,  the  twisted  end  of 
the  stillette  projects  about  the  eighth  of  an  inch  beyond  its  extre- 
mity.    With  the  end  of  the  handle  resting  in  the  centre  of  the 
palm,  and  grasped  by  the  middle  ring  and  little  fingers,  the  instm- 
ment  is  passed  down  to  the  membrana  tympani,  and  then  its  spirml 


point  ia  inserted  into  either  the  anterior  vibrating  portion  or  the 
posterior  clear  space,  and  given  one  or  two  turns,  so  as  to  fix  it 
into  the  membrane,  which,  being  thus  held  fast,  the  bur  or  nut  on 
the  end  of  the  canula  is  twisted  between  the  thumb  and  index 
finger  outwards,  or  from  the  operator,  until  by  this  circular  mo* 
tion  the  cutting  end  of  the  punch,  revolving  against  the  portion 
of  the  membrane  held  by  the  end  of  the  stillette,  cuts  it  out  and 
removes  it  entire,  leaving  a  round  aperture  the  size  of  itself.  This 
operation  can  only  be  safely  performed  with  the  aid  of  the  specu- 
lum, and  by  having  a  stream  of  clear  sunlight  transmitted  to  the 
membrane.  The  head  must  be  held  against  some  resisting  sub* 
stance,  and  the  patient  should,  if  the  Eustachian  tube  be  free,  be 
directed  to  inflate  the  tympanum  at  the  moment.  Still,  the  great- 
est delicacy  of  manipulation,  and  a  fine,  educated  touch,  are  re- 
quisite. The  objection  to  this  and  any  similar  instrument  is  that, 
from  its  size  and  the  position  of  the  handle,  the  view  of  the  parts 
under  operation  is  obscured.  To  remedy  this  defect  Mr.  Tearsley 
had  an  instrument  made  with  a  bend  near  the  handle, — ^upon  the 
principle  of  the  curve  which,  some  years  ago,  I  recommended  in 
the  formation  of  all  instruments  employed  upon  the  membrana 
tympani,  and  described  at  page  57. 

With  respect  to  the  best  situation  for  perforating,  we  find  in 
books  cautions  about  avoiding  the  chorda  tympani  nerve,  which 
are  quite  unnecessary;  for,  in  its  arch  across  the  tympanum,  it  is 
always  far  above  the  middle  of  the  space  either  in  front  of  or  be- 
hind the  extremity  of  the  malleus. 

In  cases  of  permanent  thickening  and  opacity  of  the  membrana 
tympani,  which  have  resisted  all  efforts  at  absorption  and  thin- 
ning, are  we  j  ustified  in  performing  perforation  ?  I  believe  in  very 
few  cases  indeed  will  it  be  found  efficacious,  because  the  opacity 
which  we  do  see  is  but  a  portion  of  the  general  thickening  and 
disorganization  of  the  investing  membrane  of  the  middle  ear,  per- 
haps that  of  the  labyrinth  also,  which  we  do  not  see.  It  may, 
however,  be  tried  without  injury  in  some  cases,  but  it  requires 
very  great  caution  and  dexterity  indeed  in  its  performance ;  and,  as 
irreparable  mischief  has  at  times  proceeded  from  its  being  done  in 
a  rough  or  clumsy  manner,  I  beg  to  offer  a  few  observations  on  the 



safest  method  of  performing  it.  I  wholly  discard  all  instruments 
in  the  shape  of  punches,  trocars^  and  complicated  apparatus  for 
the  removal  of  a  portion  of  the  membrane ;  because  they  all  oc- 
cupy so  much  space  within  the  speculum  that  it  is  not  possible  to 
see  accurately  the  point  of  the  membrane  which  they  are  pressing 
upon,  nor  how  much  of  it  they  are  cutting ;  and,  by  our  not  see- 
ing accurately  the  surface  on  which  we  are  working,  it  is  scarcely 
possible  to  avoid  injuring  the  malleus,  or  wounding  the  inner  wall 
of  the  tympanum ;  and,  moreover,  those  with  corkscrew  points, 
which  fix  the  membrane  while  the  revolving  punch  cuts  out  the 
piece,  are  not  only  exceedingly  painful,  but  dangerous,  inasmuch 
as  the  slightest  motion  of  the  head  during  the  operation  might  pfx>- 
duce  a  degree  of  violence  which  would  be  destructive  to  this  deli- 
cate structure. 

Having  brought  the   membrane  fairly  within  view,   under 
bright,  direct  sun-light,  I  introduce  this  small,  sickle-shaped  knife» 

—  with  a  double- cutting  edge,  and  here  figured  of  the  natural 
size  in  the  blade,  but  with  the  shaft  and  handle  about  two  inches 
longer;  and  having  made  the  patient  inflate  the  tympanum,  so  as 
to  render  the  membrane  tense,  and  pressed  outwards,  I  gently  in- 
troduce the  point  of  the  knife  into  its  inferior,  thin,  vibrating 
portion,  and,  drawing  it  downwards  and  forwards,  make  a  simple 
incision  of  the  membrane,  about  a  line  and  a  half  in  length.    Oc- 
casionally I  make  a  crucial  incision.     So  simple  is  this,  and  so 
little  pain  does  it  give,  that  the  patient  is  often  unconscious  of  its 
performance  until  made  aware  of  its  completion  by  the  air  rushing 
out  through  the  aperture.     In  about  a  minute  a  slight  oozing  of 
blood  takes  place  from  the  edges  of  the  aperture,  like  that  which 
follows  a  wound  of  the  sclerotic  with  an  ordinary  broad  cataract 
needle ;  if  left  in  this  condition  it  would  soon  heal  up ;  therefore, 
a  very  fine  probe,  fixed  in  a  handle,  and  slightly  pointed  with 
nitrate  of  silver  by  being  immersed  in  the  caustic  when  heated  to 
fluidity,  should  be  immediately  passed  down  into  the  perforation, 
the  edges  of  which  are  thereby  cauterized  and  prevented  adhe- 
ring; and  this  latter  process  should  be  repeated  from  time  to  time. 


as  often  as  the  wound  shows  an  inclination  to  heal,  and  until  we 
establish  a  sufficiently  large  elliptical  opening. 

In  1846»  Dr.  Butcher,  of  this  city,  read  a  paper  before  the 
Surgical  Society,  on  the  subject  of  Perforation  of  the  Membrana 
Tympani,  with  a  view  of  showing  the  ill  consequences  resulting 
from  the  performance  of  that  operation :  and  related  the  cases  of 
two  young  persons,  a  man  and  a  woman,  in  both  of  whom  it  would 
appear  that  death  ensued  from  puncturing  the  membrane.  Where 
fatal  consequences  are  said  to  result  from  an  operation  which 
heretofore  has  proved,  to  say  the  least  of  it,  innoxious,  it  is  of 
very  great  importance  that  we  should  inquire  into  all  the  circum- 
stances attending  such  cases,  and  the  mode  of  performing  the 
operation.   The  first  instance  was  that  of  a  young  woman,  said  to 
be  deaf  in  both  ears  for  four  years,  the  only  history  of  whose  case 
is,  that  prior  to  that  period  she  got  a  severe  cold,  with  a  swelling 
of  the  glands  of  the  neck ;  but  what  was  the  cause  of  her  deafness, 
how  it  arose,  what  was  the  condition  of  the  membrana  tympani, 
why  the  operation  was  performed,  in  what  manner,  by  whom,  or 
with  what  instrument,  we  are  not  informed ;  all  we  know  is,  that 
**  catheterism  of  the  Eustachian  tube  was  performed,  and  said  to 
fail;  hence  it  was  agreed  upon  that  the  membrane  of  the  tympanum 
should  be  pierced,  a  small  piece  being  drilled  out  of  the  membrane 
of  the  right  side  ;**  but  we  are  not  told  any  other  circumstances 
attending  the  operation,  nor  who  witnessed  it.     Pain  and  other 
evidences  of  inflammation  in  the  ear  ensued,  and  profuse  discharge 
took  place,  but  what  the  condition  of  the  ear  was  we  know  not. 
At  the  end  of  four  months  she  died,  with  symptoms  of  diseased 
brain ;  and  upon  examination  it  was  found  that  the  dura  mater 
covering  the  petrous  portion  of  the  temporal  bone  was  roughened 
and  softened  in  its  texture,  particularly  near  the  internal  auditory 
foramen.     The  membrana  tympani  was  entirely  destroyed^  and  the 
lining  membrane  of  the  tympanum  thickened  and  villous.     Now, 
while  we  are  totally  in  the  dark  as  to  what  the  original  condition 
of  this  case  was,  it  is  manifest  that  some  great  violence  must  have 
been  done  to  the  drum  of  the  ear  in  the  performance  of  the  ope- 

The  second  case  is  equally  defective  as  to  the  cause  of  deafness 

298  naFOBATioH  of  tub  mbmbbana  ttmpavi. 

or  the  appearance  of  the  ear,  although  the  post-mortem  examina- 
tion was  most  interesting ;  all  Dr.  Butcher  states  is,  that  the  man  was 
deaf  for  twelve  months  previously ;  that  he  then  applied  to  a  sur- 
geon, and  had  his  tympanum  pierced  (  ?) ;  but  why,  or  whether  with 
a  gimlet  or  a  punch,  a  trochar  or  a  probe,  we  are  not  informed* 
At  first  the  hearing  was  improved,  but  then  relapsed ;  after  some 
time  head  symptoms  set  in,  and  the  man  died  in  the  course  of  six 
weeks.  Upon  dissection,  evident  traces  of  inflammation  of  the 
brain  and  its  membranes  were  discovered ;  the  dura  mater  in  par- 
ticular, covering  the  auditory  portion  of  the  temporal  bone,  was 
rough  and  thickened,  and  a  small  abscess  was  discovered  in  the 
anterior  lobe  of  the  brain,  upon  the  same  side  on  which  the  perfora- 
tion was  said  to  have  been  performed.  In  this  case,  however,  the 
original  cause  of  the  deafness,  namely,  a  small  tumour  about  the 
size  of  a  bean,  lying  on  the  auditory  portion  of  the  seventh  pair 
of  nerves,  was  discovered.  This  was  evidently  a  case  in  which 
the  operation  never  should  have  been  resorted  to.  Dr.  Butcher 
deserves  much  credit  for  making  those  cases  public,  but  it  is  to  be 
regretted  that  the  statement  of  the  surgeon  who  performed  the 
operation,  whatever  it  was,  was  not  obtained,  nor  the  appearances 
of  the  ear,  both  before  and  after  the  operation,  described.  (Th 
cases  are  detailed  in  the  Dublin  Medical  Press,  April  1,  1846.)^ 


An  aperture  of  the  membrana  tympani  may  occur  from  a 
riety  of  causes.  It  may  exist  congenitally,  it  may  happen  by  acci- 
dent, such  as  a  penetrating  instrument,  a  foreign  body  in  the 
meatus,  loud  sudden  noises,  sneezing,  coughing,  or  blowing  the 
nose,  diving  to  any  great  depth,  falls  and  blows  upon  the  head, 
all  of  which  have  been  detailed  under  the  head  of  wounds  and 
injuries  of  this  structure,  at  page  220.  We  now  come  to  inquire 
into  its  condition  when  perforated  by  disease,  the  result  of  inflam- 
mation, &c.  An  ulcer  may  eat  its  way  through,  and  leave  from 
loss  of  substance  a  permanent  opening ;  but  the  most  frequent  cause 
of  perforation  is  otitis,  or  inflammation  of  the  membrane,  in  com- 
mon with  the  lining  of  the  ca vitas  tympani ;  when  in  the  suppura- 
tion which  ensues,  the  pent-up  matter  bursts  through  the  inflamed 


membrane  as  the  nearest  external  outlet,  and  the  case  is  then  one 
of  otorrhoea.  I  do  not  think  the  membrana  tjmpani  is  often  per- 
forated as  the  result  of  inflammation  confined  to  its  own  proper 

In  cases  of  perforation,  the  opening  is  generally  opposite  the 
aperture  of  the  Eustachian  tube,  which  would  rather  lead  us  to 
believe  that  it  is  caused  by  a  burst  or  rupture  of  the  membrane^ 
owing  to  a  sudden  jet  of  air  striking  against  this  thin  portion  of  it 
while  in  a  state  of  inflammation  and  tension,  rather  than  that  it 
was  produced  by  either  sloughing  or  ulceration.  When  a  cornea 
is  about  to  perish  in  whole  or  in  part  from  sloughing,  hypopyum, 
or  penetrating  ulcer,  we  have  an  opportunity  of  observing  the  pro- 
cess from  hour  to  hour.  It  is  not  so,  however,  in  ca^es  of  inflam- 
mation of  the  ear;  we  have  seldom  an  opportunity  of  examining 
the  part  until  the  mischief  has  occurred.  When  the  disease  hap- 
pens during  measles  or  scarlatina,  the  ordinary  medical  attendant 
pays  but  little  attention  to  the  state  of  the  ears,  although  the  pa- 
tient frequently  complains  of  excruciating  pains  therein.  He  is 
satisfied  with  attending  to  the  state  of  the  fever  and  the  eruption, 
telling  the  friends  that  the  aural  aflection  can  be  easily  rectified 
after  the  patient's  recovery.  It  must,  however,  be  acknowledged, 
that  in  many  instances  the  general  symptoms  of  the  disease  are  of 
such  a  threatening  character,  that  both  the  physician  and  the  friends 
are  well  satisfied  if  the  patient  escapes  with  life.  Nevertheless, 
I  cannot  but  feel,  that  an  examination  with  the  speculum  should 
be  made  in  all  such  cases,  and  means  taken  to  relieve  the  aural  dis- 
ease by  the  application  of  a  few  leeches,  &c.  I  have  frequently 
saved  eyes  in  patients  labouring  under  small- pox,  by  employing 
the  ordinary  remedies  applicable  to  pustules  in  the  cornea. 

In  cases  of  inflammation  of  the  middle  ear  and  membrana 
tympani,  we  will  generally  find,  upon  examination,  that  the  latter 
is  one  uniform  sheet  of  redness,  without  any  appearance  of  point- 
ing, sloughing,  or  ulceration;  and,  within  a  few  hours  after,  the 
patient  will  tell  us  that  he  is  relieved  of  his  pain  by  something 
having  suddenly  burst  in  his  ear,  and  then,  upon  inspection,  we 
find  an  opening  in  the  membrana  tympani. 

In  perforation,  particularly  if  the  aperture  is  large,  the  patient 


generally  complains  of  some  of  the  water  getting  into  the  throat 
in  syringing. 

At  page  139,  I  have  already  remarked  upon  the  general  cha- 
racters and  roost  usual  position  of  the  aperture  in  the  membrane. 
Where  there  is  no  obstruction  in  the  meatus,  we  can,  by  directing 
a  stream  of  strong  sunlight  through  the  speculum,  easily  detect 
the  rupture,  unless  it  is  either  very  small  or  valvular.    If  of  long 
standing,  its  edge  is  generally  red  and  thickened,  and  the  space 
behind  it  is  usually  very  dark,  but  we  cannot  be  certain  of  the 
precise  colour  unless  the  aperture  is  of  a  moderate  size.     When  a 
large  portion  of  the  membrane  has  been  removed,  as  is  often  the 
case  in  ears  long  affected  with  otorrhoea,  we  can  with  facility  per- 
ceive the  colour  of  the  mucous  membrane  of  the  tympanum,  which 
from  its  exposure,  and  the  state  of  chronic  irritation  in  which  it 
must  be,  is  usually  thickened,  often  granular,  and  always  of  a  deep 
bright  red ;  and,  moreover,  the  edge  of  the  aperture  throws  a  dark 
shadow  upon  the  inner  wall  of  the  tympanum  beyond,  which  we 
can  alter  by  changing  the  position  of  the  head  or  the  speculum, 
in  the  same  way  that  a  shadow  is  seen  between  the  margin  of  the 
pupil,  and  an  opaque  lens  behind,  if  the  two  are  not  in  contact 
In  cases  of  extensive  destruction  of  the  membrane,  where,  upon 
introducing  the  speculum,  we  merely  observe  a  florid Ved  vascular 
surface,  an  unpractised  eye  may  find  it  difficult  to  determine  by 
mere  inspection  whether  the  surface  brought  into  view  at  the  bot- 
tom of  the  meatus  is  the  surface  of  a  carneous  membrana  tympani 
or  the  inner  wall  of  the  tympanum  itself.     The  difference  can  at 
once  be  distinguished  by  passing  down  a  fine  probe,*  and  gently 
percussing  the  surface  we  are  looking  at,  and  if  it  be  that  of  the 
tympanum,  a  delicate  touch  at  once  detects  the  difference  of  tex- 
ture ;  while,  if  the  contrary,  the  patient  is  always  conscious  of  some- 
thing knocking  against  the  skull,  but  generally  complains  less  than 
if  the  probe  touched  the  membrana  tympani.    The  part  most  usu- 
ally presented  is  the  promontory. 

*  When  we  have  occasion  to  use  a  probe  for  examining  the  ear,  it  should  be  aboat 
three  inches  long,  fixed  in  a  handle,  have  rather  a  large  button  on  the  end,  and  be  rerj 
slender  for  about  an  inch  behind  the  extremity,  so  that  it  will  bend  with  fS^ilitj  afaonld 
the  patient  more  th«  head  in  th«  dfanetion  of  the  instniment. 


When  the  membrane  has  been  eaten  away  by  ulceration,  or  so 
much  of  Its  lower  portion  destroyed  by  rupture  or  other  circum- 
stances as  to  cease  to  be  a  fixed  point  for  the  manubrium  of  the 
malleus,  the  ossicula,  or  at  least  whatever  remnant  of  them  re- 
mains, are  drawn  upwards  and  backwards,  and  generally  present 
with  the  remaining  portion  of  the  membrane  a  well-defined  pro- 
tuberance, generally  whiter  than  the  rest. 

Where  we  have  any  difficulty  in  detecting  an  aperture,  we 
should  direct  the  patient  to  force  air  into  the  drum,  when  the 
squeeling,  gurgling,  or  whistling  sound  produced  by  its  transit 
through  the  rupture  will  decide  the  question, — supposing  the 
Eustachian  tube  to  be  free,  which,  in  some  cases,  it  is  not.  When, 
in  cases  of  recent  otitis,  the  meatus  is  thickened,  and  both  it  and 
the  external  surface  of  the  membrana  tympani  covered  with  a  layer 
of  white  macerated  cuticle  and  flakes  of  discharge,  it  is  sometimes 
difficult,  by  mere  inspection  alone,  to  decide  the  question,  particu- 
larly if  direct  sunlight  is  not  available  at  the  moment.  Some  time 
ago  I  described  two  diagnostic  symptoms,  one  or  other  of  which, 
when  present,  are  unfailing  indications  of  rupture.  If,  on  look- 
ing into  the  meatus,  even  without  a  speculum,  we  see  a  single 
globule  of  air  entangled  in  the  discharge  which  generally  fills  it, 
we  may  rest  assured  that  the  tympanal  cavity  is  open  externally. 
If  we  do  not  at  first  see  this  globule,  and  that  we  press  upon  the 
root  of  the  tragus  with  the  point  of  the  finger,  we  can  generally, 
if  the  tympanum  is  open,  bring  it  to  the  surface.  I  suppose  it  is 
forced  up  through  the  Eustachian  tube  in  sneezing  or  coughing, 
&c.,  and  finds  its  way  from  the  tympanal  cavity  to  the  surface  of 
the  fluid.  Sometimes  the  bottom  of  the  meatus  is  filled  with  seve- 
ral air-bubbles,  which  generally  coalesce  upon  the  introduction  of 
the  speculum.  Some  years  ago  I  was  called  to  see  a  gentleman  said 
to  be  labouring  under  fever ;  he  was  from  the  commencement  ex- 
tremely deaf,  and  had  complained  of  violent  pain  in  his  ears  and 
head ;  he  had  great  heat  of  skin,  loss  of  rest,  a  brown  furred  tongue, 
great  thirst,  some  intolerance  of  light,  a  very  quick  pulse,  and 
other  febrile  symptoms.  Upon  the  fifth  day  a  purulent  discharge 
was  observed  to  issue  from  both  his  ears,  when  the  attention  of  the 
medical  attendant  was  first  attracted  to  the  organs  of  hearing.     I 


saw  him  upon  the  sixth  day;  he  was  then  so  deaf  that  he  had  to 
be  communicated  with  by  writing.  On  examination  I  found  se- 
veral air-bubbles  mixed  with  the  discharge  which  poured  from 
his  ears;  and  I  at  once  stated  to  the  practitioner  in  attendance, 
what  subsequently  proved  to  be  correct,  that  the  case  was  one 
of  otitis,  in  which  the  tympanal  membranes  had  given  way  to 
allow  exit  to  the  pent-up  pus.  From  the  condition  of  the  patient 
at  the  time  I  saw  him,  it  was  not  possible  to  make  an  accurate 
examination,  neither  was  such  at  the  moment  necessary.  Two 
days  afterwards,  upon  removing  the  discharge,  an  aperture  was 
found  in  the  antero-infcrior  part  of  the  membrana  tympani,  oppo- 
site the  Eustachian  tube,  on  each  side.  These  apertures  subse- 
quently closed,  and  the  gentleman  recovered  his  hearing.  I  have 
remarked  that  a  rupture  of  the  membrane,  produced,  like  this, 
from  otitis,  heals  more  readily,  and  often  without  treatment,  than 
that  produced  by  chronic  otorrhoea ;  the  former  being  a  rupture, 
the  latter  an  ulcer,  and,  consequently,  attended  with  a  greater  loss 
of  substance.  While  correcting  these  pages,  I  was  consulted  by  a 
lady  for  deafness  of  the  left  ear.  Upon  examining  the  right,  about 
which  she  made  no  complaint,  I  found  the  membrana  tympani 
thickened  and  opaque,  except  one  abnormally  thin  portion  in  the 
centre,  which  was  rather  depressed  beneath  the  surrounding  sur- 
face. Upon  expressing  an  opinion  that  she  must  have  had  some 
inflammatory  action  in  that  ear  previously,  she  acknowledged  that 
nineteen  years  before,  she  had  had  a  **  severe  bcelding"  which  kept 
her  awake  several  nights,  until  relieved  by  a  discharge  of  matter, 
which  continued  to  flow  from  her  car  for  some  months  subse- 
quently. I  suppose  the  rent  was  filled  up  by  the  delicate  bit  of 
membrane  still  apparent  in  the  centre  of  the  drum-head. 

Another  curious  phenomenon,  which  has  not,  as  far  as  I  am 
aware,  been  previously  described  by  authors,  is, — that,  when  the 
membrane  is  perforate,  and  that  an  air  globule  exists  at  the  bot- 
tom of  the  meatus,  we  can,  by  keeping  the  eye  steadily  fixed  upon 
it, — and  as  its  bright  convex  surface  generally  reflects  the  light,  it  is 
easily  seen, — perceive  that  it  pulsates,  and  that  its  action  is  syn- 
chronous with  that  of  the  heart  and  arteries.  It  is  not  an  invariable 
symptom,  and  the  pulsation  sometimes  intermits.     In  order  to  sec 


in  perfection,  there  ought  to  be  but  a  slight  coating  of  thin  discharge 
at  the  bottom  of  the  meatus,  and  the  globule  from  which  the  light  is 
thus  brilliantly  reflected  should  be  either  entangled  in  or  opposite 
the  opening  in  the  membrana  tympani.  In  most  of  the  cases  in  which 
I  have  remarked  it,  the  aperture  was  rather  small,  and  situated  in 
the  posterior  part  of  the  membrane.  I  have  never  seen  it  where 
the  opening  was  very  large,  or  the  membrane  entirely  destroyed. 
It  is  an  additional  proof  that  the  membrane  pulsates,  certainly  in 
disease,  and  probably  in  a  normal  condition  also ;  although  we  are 
not  in  a  position  to  detect  its  motion.  (See  additional  remarks 
upon  this  subject  at  page  218.)  As  already  stated,  the  rupture 
usually  takes  place  in  the  anterior  portion,  and  close  to  the  open- 
ing of  the  Eustachian  tube ;  sometimes  it  may  be  seen  as  a  round 
or  oval  hole,  about  the  size  of  No.  8  shot,  and  appearing  as  if 
punched  out  of  the  membrane.  In  other  instances  it  occurs  at  the 
anterior  inferior  edge  of  the  membrane,  in  which  case  the  lower 
margin  of  the  aperture  is  formed  by  the  parietes  of  the  canal  and 
cavity  of  the  tympanum.  In  still  rarer  instances  the  rupture  takes 
place  in  the  posterior  division  of  the  membrane,  below,  and  some- 
what  behind,  the  point  of  the  malleus.  Sometimes  the  aperture 
presents  a  kidney  shape  round  the  manubrium,  which  projects 
into  it  like  a  peninsula. 

The  treatment  of  an  aperture  in  the  membrana  tympani,  and 
the  success  which  is  likely  to  attend  it,  must  depend  upon  its  cause, 
duration,  and  extent :  the  older,  the  less  likely  to  heal,  and  if  from 
ulceration,  it  is  also  more  unpromising  than  when  it  has  taken 
place  from  mechanical  injury  or  the  pressure  of  accumulated 

An  aperture,  even  of  considerable  size,  may  exist  in  the  mem- 
brana tympani,  without  otorrhcsa,  but  upon  the  slightest  acces- 
sion of  cold,  otorrhcea  will  occur  from  the  surface  of  the  exposed 
tympanal  cavity.  The  prognosis  is  uncertain.  I  have  sometimes 
failed  in  healing  very  small  apertures,  while  much  larger  oneshave, 
to  my  surprise,  closed,  under  treatment,  in  a  very  short  time. 

After  a  long  and  fair  trial  of  several  means  proposed  for  heal- 
ing apertures  in  the  membrana  tympani,  I  have  come  to  the  con- 
clusion, that  there  is  nothing  like  nitrate  of  silver.     It  will  not, 


however,  answer  to  thrust  a  stick  of  lunar  caustic,  fastened  in  a 
quill,  down  the  meatus,  for  the  purpose  of  touching  any  part  of  the 
membrana  tympani ;  to  be  used  with  effect,  the  escharotic  should 
be  applied  upon  the  extreme  edge  of  the  aperture,  or  rather  with- 
in the  ring  of  the  opening,  every  second  or  third  day,  so  long  as 
the  part  seems  inclined  to  close,  but  the  moment  we  perceive  it 
enlarging,  a  day  or  two  after  the  application,  we  must  desist.  As 
it  is  not  always  possible  to  reduce  a  pencil  of  nitrate  of  silver  to 
the  requisite  degree  of  fineness,  I  have,  for  several  years  past^ 
been  in  the  habit  of  pointing  probes  and  other  instruments  used 
in  minor  surgery,  with  nitrate  of  silver  attached  to  them,  in  the 
following  manner : — a  portion  of  the  caustic  is  to  be  melted  to  the 
boiling  point,  in  a  small  silver  or  platina  ladle,  such  as  that  repre- 
sented  below,  held  over  a  spirit  lamp.     When  the  caustic  has 

become  quite  clear,  the  point  of  the  probe  or  instrument  to  which 
it  is  to  be  attached  should  be  heated  in  the  flame  of  the  lamp,  and 
then  dipped  into  the  fluid  caustic  several  times,  until  a  suflEicient 
quantity  is  taken  up.  By  this  means,  we  can  point  a  needle  with 
caustic,  should  it  be  necessary  to  apply  it  to  any  minute  part, 
such  as  an  ulcer  on  the  eye,  &c.*  The  instrument  figured  below 
will  be  found  very  convenient  for  applying  nitrate  of  silver  to  any 

surface  within  the  meatus.  This  port^-cawtic  is  about  six  inches 
long,  and  consists  of  a  silver  tube,  cut  spirally  for  three-fifths  of 
its  length,  and  having  an  aperture  in  the  side,  or  a  hollow  at  end. 
When  about  to  be  used,  its  extremity  should  be  coated  with  caus- 
tic, as  already  directed.     The  elastic  spring  prevents  any  injury 

*  Dr.  M'Donnell,  of  Montrea],  formerty  of  Dablin,  wrote  ao  article  in  the  Medical 
Journal  of  that  dtj  some  jears  ago,  to  show  that  I  was  not  the  original  inventor  of  thb 
ingenioos  application  of  this  very  useful  remedj,  and  that  Dr.  Morgan  of  this  city  was 
the  person  to  whom  the  credit  belongs.  When,  in  January,  1S44,  I  first  recommended  it, 
I  feel  sure  that,  if  I  had  remembered  Dr.  Morgan's  suggestion,  I  would  hare  ""yynrtiMied 
it,  as  I  have  all  my  life  laboured  to  "  render  tribute  to  whom  tribute  is  due  ;'*  and  I  there- 
fore take  this  opportunity  of  rendering  my  townsman  due  credit  for  the  suggestion. 


to  the  car  from  the  starting  of  the  patient,  and  can  also  be  bent, 
so  as  to  be  applied  with  ease  to  any  part  of  the  auditory  canal. 
When  granulations  sprout  from  a  perforation  in  the  membrane — 
which  is  very  rare,  unless  the  rupture  occurs  immediately  adjoin* 
ing  its  edge — this  mode  of  applying  caustic  will  be  found  very 
e£fectual,  as  well  as  for  the  eradication  of  small  polypi ;  but  I 
have  never  yet  seen  a  polypus  attached  to  the  membrana  tym- 

When  the  membrana  tympani  is  perforated,  and  that  we  touch 
it,  or  a  polypous  growth,  or  sometimes  even  an  abraded  spot  upon 
the  surface  of  the  meatus,  with  solid  nitrate  of  silver,  it  is,  in  many 
cases,  tasted  in  the  mouth  almost  immediately,  but  only  on  the 
side  to  which  it  has  been  applied.  Patients  say,  '*  they  feel  the 
impression  of  the  caustic  running  down  along  that  side  of  the 
tongue,  but  not  reaching  the  lip."  I  never  knew  this  peculiarity, 
except  where  there  was  a  hole  in  the  membrane.  Is  it  transmit- 
ted by  continuity  of  mucous  surface,  or  by  means  of  the  chorda 
tympani  ? 

The  following  case.  No.  2  in  the  Registry,  of  chronic  thick* 
ening  of  the  left,  and  total  loss  of  the  right,  membrana  tympani, 
will  be  found  illustrative  of  the  foregoing  observations : — 

E.  S.,  a  female,  aged  25,  suffered  from  disease  of  the  ears  since 
she  had  scarlatina,  three  or  four  years  ago ;  has  had  *'  a  running** 
from  one  ear,  but  never  experienced  any  pain  on  either  side,  and 
never  had  medical  advice.  A  constant  buzzing  noise  is  present 
in  the  left  ear ;  none  whatever  in  the  right.  Hearing  distance  on 
the  right  side,  five  inches ;  on  the  left  only  on  pressing  the  watch 
to  the  external  ear ;  hears  the  watch  well  on  placing  it  between 
the  front  teeth.  Upon  examination,  we  find  chronic  inflamma- 
tion, attended  with  muco-purulent  discharge,  in  the  right  ear.  On 
bringing  the  bottom  of  the  meatus  auditor! us  into  view,  we  per- 
ceive a  smooth,  deep-red j  moist,  and  irregularly  concave  surface: 
this  is  the  inner  wall  of  the  tympanum,  the  mucous  membrane  co- 
vering which,  by  being  so  long  exposed  to  the  atmosphere,  has 
assumed  this  peculiar  florid  and  villous  appearance.  The  eye  in- 
forms us  that  we  are  not  looking  at  the  membrana  tympani ;  the  pe- 
culiar curve  of  the  surface  that  meets  the  view,  the  hue  of  colour, 



and  the  great  depth  at  which  it  is  placed,  would,  even  if  one  were 
not  well  acquainted  with  the  appearance,  at  once  lead  us  to  say 
that  the  membrane  had  been  removed ;  and,  on  passing  down  a 
fine  round-headed  probe,  it  knocks  against  the  bony  protuberance 
of  the  promontory.  The  spot  where  the  probe  touched  has  be- 
come of  a  much  deeper  red,  and  the  patient  says  she  ezperienoed 
a  sensation  as  if  something  was  knocking  loudly  against  the  side 
of  lier  head.  Towards  the  upper  and  posterior  side  there  is  a 
white  projection,  the  displaced  malleus,  from  which  a  shadow  is 
thrown  upon  the  red  surface  of  the  tympanal  cavity.  The  sha- 
dow thrown  from  it  proves  that  it  is  not  in  contact  with  the  deep 
surface  we  are  looking  at :  in  the  same  way  as  the  shadow  cast 
by  the  pupillary  margin  of  the  iris  tells  us  the  position  of  the  opa- 
city, and  other  circumstances  of  great  importance,  in  a  practical 
point  of  view,  in  cases  of  cataract.  Towards  the  lower  and  ante- 
rior edge  of  the  cavity  may  be  observed  a  spot  darker  than  the 
rest, — the  aural  opening  of  the  Eustachian  tube,— -but  the  patient 
is  unable  to  pass  air  through  it.  When  this  tympanal  membrane 
was  destroyed  we  know  not ;  probably  an  aperture  occurred  in  it 
during  the  scarlet  fever,  from  which  she  suffered  at  the  time  her 
deafness  came  on,  and,  by  ulceration,  it  has  since  extended.  I 
am  inclined  to  think  this  has  been  the  process ;  for  she  says  the 
discharge  under  which  she  formerly  laboured,  and  which  was 
so  great  as  to  pour  out  of  the  external  meatus  and  soil  her 
dress,  has  of  late  considerably  lessened,  and  is  now  very  slight, 
and  about  the  consistence  of  made  starch.  This  accords  with 
my  experience  of  those  discharges.  In  cases  of  polypus,  with- 
out any  aperture  in  the  tympanal  membrane,  the  discharge  is 
always  profuse,  and  usually  purulent;  where  there  is  an  aper- 
ture in  the  membrane,  it  is,  generally  speaking,  not  so  abundant, 
but  more  mucous ;  and  where  the  membrane  has  been  almost  en- 
tirely removed,  as  in  this  case,  the  discharge  frequently  lessens. 
Sometimes  there  is  scarcely  sufficient  secretion,  and  patients  are 
in  the  habit  of  moistening  the  ear  with  a  drop  of  water  applied 
with  the  end  of  the  finger.  I  know  a  gentleman  who  does  so 
every  day  after  dinner  when  he  wishes  to  hear  well,  and  he  has 
an  aperture  in  his  membrana  tympani.     As  already  stated,  this 


patient  has  no  noise  upon  this  (the  right)  side.  Where  the  mem- 
brane has  a  large  aperture  in  it,  or  has  been  completely  removed, 
I  have  generally,  but  not  invariably,  observed,  that  there  is  no 
tinnitus  aurium,  or,  if  such  existed  upon  the  first  accession  of 
deafness,  it  ceases  as  soon  as  the  membrane  has  become  so  much 
destroyed  as  in  this  case,  unless  it  had  been  originally  cerebral. 
Therefore  it  is  that  some  persons  have  derived  relief  from  this 
most  distressing  symptom  by  having  the  membrane  perforated, 
although  the  removal  of  the  deafness  could  not  be  expected. 

This  woman  hears  at  five  inches  distance  upon  the  right  side ; 
but  she  hears  the  voice  better  than  other  persons  who  possess  a 
hearing  distance  by  the  watch  of  some  inches  more :  this  is  worthy 
of  remark,  and  applies  to  a  vast  number  of  deaf  cases.  Some  per- 
sons are  better  able  to  understand  the  purport  of  discourse  firom  a 
natural  quickness  of  comprehension,  and  will  maintain  a  conver- 
sation although  they  cannot  hear  the  watch  at  two  inches  distance ; 
while  others  who  hear  the  watch  at  three  times  that  distance  ex- 
hibit a  dulness  of  general  hearing  that  is  quite  remarkable.  I 
have  observed  that,  when  once  the  tympanal  membrane  has  be- 
come permanently  open,  the  larger  the  aperture,  the  greater  the 
amount  of  hearing,  provided  no  further  mischief  has  taken  place, 
and  that  there  is  a  slight  ring  or  circle  of  the  membrane  still  re- 

Artificial  Membrana  Tympard, — A  complete  cure  for  deafiiess 
arising  from  an  aperture  of  the  tympanal  membrane,  by  passing 
a  portion  of  wool  or  raw  cotton,  moistened  with  some  fluid,  into 
the  bottom  of  the  meatus,  was  published  in  July,  1848.  I  became 
aware  of  the  fact  about  eight  years  ago,  through  a  lady  resi- 
dent in  Clonmel,  who  discovered  it,  she  told  me,  by  accident. 
Considering  hers  an  isolated  case,  and  having  my  attention  di- 
rected particularly  to  other  subjects  at  the  moment,  I  thought  no 
more  about  the  matter  then.  The  lady  informs  me,  in  answer  to 
a  recent  communication,  that  the  disease  in  her  ears  originated  in 
what  she  styles  brain  fever,  eighteen  yfttrs  ago,  but  that  the  phy- 
sicians whom  she  consulted  told  her  that  her  aural  affection  was 
merely  nervousness,  and  that  the  drums  of  her  ears  were  quite 
unaffected.     *'  Suffering,**  she  says,  *<  so  dreadfully  from  deafness, 



and  a  suffocating  feel  about  my  head,  I  resorted  to  many  experi- 
ments.    At  last  I  was  recommended  to  try  a  piece  of  fiit  bacon, 
toasted  over  a  candle,  and  then  put  into  the  ears.     I  used  it  for  a 
long  time,  but  eventually  I  was  obliged  to  discontinue  it,  as  it 
hurt  me  very  much.  I  then'dropped  oil  into  my  ears  instead,  and  it 
for  a  while  enabled  to  hear,  but  in  an  hour  or  two  afterwards  I 
used  to  be  as  deaf  as  ever ;  so  I  naturally  thought  that,  by  pattiiig 
a  little  wool  with  the  oil  into  my  ear,  and  thus  keeping  up  the 
moisture,  it  would  answer  the  purpose.     This  I  tried,  and  found 
it  most  efficacious.     I  must,  however,  have  it  settled  in  one  par- 
ticular spot  in  my  ear,  or  it  would  be  quite  useless,  and  were  I  to 
take  it  out  I  would  not  hear  a  word.     I  generally  arrange  it  with 
a  large  pin  or  bodkin,  and,  when  fixed  properly,  I  have  no  occa- 
sion to  change  it  for  three  days  together." — A.  Mc  S. 

To  Mr.  Yearsley  we  are,  however,  indebted  for  making  this 
valuable  discovery  known,  as  already  stated  at  page  35;  and  al- 
though Deleau  and  others  have  claimed  acquaintance  with  the 
fact,  it  is  manifest  that  they  made  no  use  of  it*  The  subject  is 
one  that  has  lately  engaged,  and  very  justly,  much  attention,  and 
I  have  recently  verified  in  numerous  cases  the  opinion  which  I 
have  on  a  former  occasion  expressed  of  its  value. 

A  gentleman,  about  fifty  years  of  age,  caught  a  violent  cold 
by  being  much  exposed  during  the  night  air  among  some  of  the 
snowy  mountains  and  glaciers  of  Switzerland  a  year  and  a  half 
previous  to  the  time  I  saw  him.  He  was  attacked  with  dull  ach- 
ing pains  in  his  ears,  attended  with  considerable  deafness.  He 
said — and  being  a  person  of  great  intelligence  and  some  scientific 
acquirements,  I  was  constrained  to  believe  his  statement — thati 
upon  applying  for  advice  in  one  of  the  large  towns  in  Switzerland, 
a  mixture  containing  muriatic  acid  was  prescribed  for  him,  in 
order  '^  to  alleviate  the  pain  and  stimulate  the  drum  of  his  ears." 
Shortly  after  the  first  application,  which,  unfortunately,  was  made 
on  both  sides,  he  had  a  violent  attack  of  ear-ache,  which,  he  states, 
^'nearly  set  him  mad,**  but  that  he  got  relief  as  soon  as  something 
burst  in  his  ears,  and  that  a  discharge  was  established.     Ebtving 

*  See  Medical  Times  for  12tb  April,  1851,  p.  412. 


heard  of  the  glycerine-and-cotton  remedy,  he  applied  it,  and  suc- 
ceeded once,  but  never  after,  in  gaining  relief  Upon  inquiry,  I 
found  that  he  had  completely  filled  the  meatus  with  a  plug  of 
wool  and  glycerine.  On  examination,  I  found  that  the  tympanal 
membrane  had  been  altogether  removed  upon  one  side,  and  but 
a  slight  remnant  of  it  remained  upon  the  other.  He  had  a  good 
deal  of  discharge ;  no  noise ;  but  he  was  so  deaf  that  one  required 
to  shout  to  him ;  and  he  came  to  me  to  recommend  him  some  sort 
of  hearing-trumpet.  The  mucous  membrane  of  the  tympanal  ca- 
vity and  the  meatus  were  in  a  state  of  chronic  inflammation, 
which,  being  lessened  by  the  application  of  a  solution  of  nitrate 
of  silver  and  other  means  employed  for  a  few  days,  I  introduced 
bits  of  moistened  cotton  in  the  manner  previously  described.  His 
hearing  was  instantaneously  restored ;  and,  having  taught  him 
after  a  few  visits  how  to  manage  the  application  himself,  be  was 
again  able  to  join  society  almost  as  well  as  ever. 

Highly  valuable,  however,  as,  no  doubt,  this  remedy  is,  it  is,  in 
its  application  and  usefulness,  variable.  In  some  cases  what  it  will 
effect  is  quite  marvellous, — almost  instantaneous  restoration  to 
comfortable  hearing ;  but,  in  other  instances,  it  does  not  succeed  so 
well,  or  even  at  all.  The  cases  in  which  it  is  most  effectual  are  those 
where  there  is  a  very  large  aperture  in,  but  not  a  total  destruction 
of,  the  membrana  tympani.  It  requires  some  tact  to  hit  off  the  exact 
position  in  which  to  place  the  bit  of  cotton ;  but,  the  moment  it  is 
done,  either  by  the  practitioner  or  the  patient,  the  hearing  is  re- 
stored. It  should  be  made  to  fit  on  or  into  the  aperture  in  the  mem- 
brane, not  completely  to  block  up  the  meatus,  nor  to  press  against 
the  inner  wall  of  the  tympanum.  It  ought  to  be  passed  down  with 
a  fine  forceps  or  probe,  and  patients  should  be  taught  how  to  intro- 
duce  it  themselves ;  the  lady  by  whom  I  first  saw  it  employed  al- 
ways carried  a  bodkin,  a  little  fine  wool,  and  a  bottle  of  oil,  for  the 
purpose.  I  do  not  think  it  matters  much  what  the  fluid  is ;  I  ge-» 
nerally  use  fine  oil,  and,  after  the  bit  of  cotton  is  saturated  with 
it,  I  press  it  gently  between  the  fingers.  As  there  is  always  some 
discharge  from  the  exposed  mucous  membrane  in  these  cases,  a 
sufficient  moisture  is  kept  up  for  two  or  three  days ;  but  the  wool 
or  cotton  should  be  removed  from  time  to  time,  according  to  the 


patient's  own  sensations,  and  never  allowed  to  remain  in  longer 
than  three  or  four  days.  If  there  be  much  discharge  present^  the 
wool  or  cotton  may  require  removal  daily.  It  is  astoniahing  with 
what  adroitness  a  patient  will  sometimes  hit  off  the  necessary  po- 
sition of  the  cotton,  even  after  the  practitioner  has  failed  to  adjust 
it.  Notwithstanding  some  ingenious  attempts  at  explanation,  we 
still  require  a  feasible  solution  as  to  how  this  remedy  acts. 

Mr.  Toynbee  has  recently  recommended  a  thin  plate  of  vulca- 
nized India  rubber  or  gutta  percha,  attached  to  a  wire  stem,  as  an 
artificial  tympanic  membrane,  in  lieu  of  the  wool  or  cotton  re- 
medy.* I  have  no  experience  of  it ;  but  I  doubt  its  general  ap- 

In  the  foregoing  chapter  I  may  to  some  have  appeared  prolix; 
but,  upon  a  subject  comparatively  so  new  in  English  literature, 
BO  little  studied,  and  consequently  so  little  understood  by  prac- 
titioners in  general,  it  was  not  possible  to  explain  my  meaning 
vnthout  entering  into  minute  descriptions.  Moreover,  from  the 
circumstance  of  the  membrana  tympani  being  the  part  most  easily 
examined,  being  that  most  frequently  affected,  and,  consequently, 
affording  the  safest  means  for  diagnosis  either  for  deafness  arising 
from  affections  peculiar  to  itself,  and  confined  to  its  own  structure, 
or  which  it  exhibits  in  common  with  other  and  deeper-seated 
structures  similarly  diseased,  it  frequently  affords  us  not  only  the 
surest  but  the  only  faithful  indication  for  forming  an  accurate  diag- 
nosis. If  aural  diseases  were  as  attentively  studied  in  these  king- 
doms as  ophthalmic  or  obstetric  affections,  then  would  the  length- 
ened description  of  cases  be  unnecessary ;  but  where  do  we  find, 
throughout  the  whole  circle  of  our  periodical  literature,  half-a* 
dozen  well  observed  and  accurately  noted  cases  of  disease  of  the 
ear  in  a  twelvemonth  ?  Faithful  observation  and  clinical  records 
of  disease  are  now  more  required  in  this  than  in  any  other  branch 
of  medical  science. 

•  See  Medical  Hmes  and  Gazette  for  Febniaiy  12,  1858. 




Anatomy  of  the  Cavitas  Tympani — Apertures,  Oasicula,  and  Investing  Membrane.-^Th* 

Eostachian  Tube  and  Tonsils. — Congenital  Malformations  of  the  Middle  Ear. 

Wounds  and  Injuries;  Hemorrhage  and  Serous  Effusion. — Inflammations:  Acute 
Otitis ;  Otonhosa ;  Subacute  Otitis ;  Exanthematous  and  lyphoid;  Acquired  Dumb« 
ness;  Fadal  Paralysis. — Rheumatic  Otitis ;  Periosteal ;  Carie& — Diseases  of  Mastoid 
Cells. — Affections  of  the  Ossicula. — Morbid  Growths  in  the  Tympanum ;  Polypus ; 
Exostosis. — Catarrhal  and  Chronic  Otitis :  Ablution,  Fumigation,  and  Bougie  Explo- 
ration of  Tympanum. — ^Malignant  Fungus. — Diseases  of  the  Eustachian  Tube ;  Fo- 
reign Bodies  in ;  Inflammation ;  Obstruction.— Throat  Deafness.-— Enlarged  Tonsik 
and  Cleft  Palate. 

ALTHOUGH  I  have  separated  the  diseases  of  the  Eustachian 
tube  firom  those  of  the  cavitas  tympani  in  the  Nosological 
Table,  in  accordance  with  the  anatomical  basis  observed  in  their 
general  division ;  still,  in  a  pathological  point  of  view,  these  two 
parts  may  as  fairly  be  classed  together  as  the  diseases  of  the  middle 
ear  and  the  mastoid  cells. 

The  middle  division  of  the  auditory  apparatus,  the  tympanum 
or  cavitas  tympani,  is  that  space  between  the  membrana  tympani 
externally,  which  separates  it  from  the  auditory  tube,  and  the 
outer  wall  of  the  internal  ear  or  labyrinth.  It  resembles  the  form 
of  its  external  septum,  but  is  rather  more  irregular  in  its  cir* 
cumferential  boundary.  It  is  somewhat  wedge-shaped,  being  nar- 
row below  and  broad  above,  owing  to  the  oblique  position  of  the 
membrana  tympani,  and  measures  about  three-eighths,  or  from  that 
to  half  an  inch  in  its  longest  diameter.  In  the  dry  bone  it  has  five 
special  outlets, — externally  into  the  osseous  meatus; — internally 
by  two  small  apertures,  which  communicate  with  the  labyrinth, 
called  from  their  shape  the  round  and  the  oval  window, — two  pro- 
ceeding from  the  circumference ;  of  these,  that  anteriorly,  and  a 
little  below  the  middle  horizontal  line,  is  the  entrance  of  the  Eusta- 
chian tube,  which  communicates  with  the  throat ;  and  one  or  more 
openings  lead  in  the  adult  into  the  mastoid  cells  superiorly  and 


posteriorly.  Viewed  from  without,  by  making  a  section  of  the  tem- 
poral bone  immediately  beyond  the  groove  for  the  attachment  of 
the  membrana  tympani,  we  observe  upon  its  inner  wall  a  projectioii 
of  densely  hard  bone  dividing  the  two  apertures  already  alluded 
to,  both  of  which  are  placed  in  the  posterior  half,  and  consequently 
immediately  opposite  the  external  outlet  of  the  osseous  auditoiy 
canal  and  the  posterior  vibrating  portion  of  the  membrana  tympam. 
This  protuberance  is  the  promontory  caused  by  the  projection  of 
the  cochlea :  the  inferior  opening  is  the  fenestra  rotunda,  somewhat 
triangular  in  shape,  and  in  the  recent  state  closed  by  a  delicate 
membrane  analogous  to  the  membrana  tympani,  and  which  may  be 
called  the  internal  drum-head,  which  separates  the  tympanum 
from  the  extremity  of  the  cochlea,  and  hence  called  the  fenestra 
cochleae.   As  this  membrane  serves  to  transmit  vibrations  of  sound, 
and  is  the  only  barrier  to  the  escape  of  the  fluid  contained  within 
the  labyrinth,  it  is  manifest  that  any  interference  with  its  func- 
tions, any  alterations  or  organic  changes  in  its  structure,  or  its  to- 
tal destruction  from  sloughing,  ulceration,  or  caries  of  its  bony 
attachment,  must  be  attended  with  considerable  impairment^  if 
not  total  loss,  of  hearing.    When  the  tympanic  cavity  is  exposed 
by  extensive  destruction  of  its  outer  membrane,  we  do  not  see  the 
little  membrane  ofthe  cochlear  fenestra;  the  whole  looks  oneuni« 
form  red  surface,  and  in  this  state  the  physiology  of  hearing  has  not 
yet  been  satisfactorily  explained ;  but  I  presume  that  the  waves  of 
sound  impinge  directly  upon  this  membrane,  and  sensations  are  thus 
conveyed  to  the  internal  ear.  That  the  membrane  vibrates  is  proved 
by  experiment,  and  one  use  of  it  may  be  to  allow  the  fluid  con- 
tained within  the  vestibule,  when  pressed  upon  by  the  base  of  the 
stapes — covering,  like  a  lid,  the  fenestra  ovalis — to  bulge  a  little 
into  the  cavity  of  the  tympanum.     But  that  this  latter  must  be  a 
secondary  object  is  proved  by  the  amount  of  hearing  possessed  by 
persons  who  have  suffered  from  extensive  destruction  of  the  mem- 
brana tympani,  or  have  even  lost  some  ofthe  ossicles. 

The  superior  opening  is,  as  its  name  implies,  oval  or  ovoid 
for  the  reception  of  the  base  ofthe  stapes,  which  fits  into  it  some- 
what like  a  stopper,  or  the  piston  of  a  cylinder,  and  is  attached 
to  its  circumferance  by  a  ligamento-fibrous  membrane,  which 
allows  a  double  motion  to  the  small  bone  which  it  surrounds^ a 


stopper-like  one  by  which  it  is  forced  towards  the  cavity  of  the 
vestibule,  with  which  this  opening  communicates, — and  a  lateral 
or  oscillating  one  by  which  each  of  its  extremities  can  be  made  to 
press  inwards  in  turn.*  The  surface  of  the  promontory  is  grooved 
for  the  ramification  of  the  tympanic  branches  from  the  glosso-pha- 
ryngeal  nerve.  Traversing  the  superior  wall  of  the  tympanum,  im- 
mediately above  the  fenestra  ovalis,  is  the  aqueduct  of  Fallopius 
for  the  transmission  of  the  facial  portion  of  the  seventh  pair  of 
nerves,  which  projects  somewhat  into  the  roof  of  the  tympanic  ca- 
vity, and  the  relations  of  which  have  already  been  remarked  upon 
at  page  214.  Posteriorly  and  immediately  below  this  conduit  of  the 
facial,  we  observe  a  little  conical  eminence  called  the  pyramid,  in 
the  apex  of  which  there  is  a  depression  leading  into  an  opening 
which  gives  insertion  to  the  stapedius  muscle. 

From  the  large  sinus  in  the  roof  of  the  tympanum,  or  some* 
times  by  one  or  two  openings  in  addition,  the  mastoid  cells  commu- 
nicate freely  with  the  cavitas  tympani,  and  it  is  of  great  importance 
to  bear  this  communication  in  mind,  when  inflammation  attacks 
the  tympanum,  which  space,  as  well  as  these  mastoid  cells,  are 
separated  from  the  cavity  of  the  cranium  by  a  thin  and  often  de- 
licate lamina  of  bone,  pierced  by  several  small  apertures  for  the 
transmission  of  vessels  to  the  dura  mater,  which  adheres  intimately 
to  the  superior  surface  of  the  bone  at  this  place. 

Anteriorly  and  somewhat  inferiorly  the  whole  side  of  the 
tympanal  cavity,  from  the  attachment  of  the  membrana  tympani 
in  front  to  the  root  of  the  promontory  behind,  may  be  seen  the 
smooth  trumpet-shaped  entrance  of  the  Eustachian  tube ;  and  not, 
as  is  described  in  books,  commencing  by  a  small  aperture ;  on  the 
contrary,  it  is  the  widest  part  of  the  bony  portion  of  that  canal. 
Along  its  posterior  margin,  somewhat  above  the  middle,  a  delicate 
concave  shelf  of  bone  stands  out,  which  forms  the  floor  of  a  canal, 

*  See  the  splendid  work  of  Professor  Hyrtl  of  Vienna,  upon  the  Comparative  Ana- 
tomy of  the  Ear,  "  Vergleiehend'antUcmUehe  UnteTtuehvngen  uber  dai  innere  Geh'ororgan 
det  Mensehen  vnd  der  SaugetkiereJ*  See  also,  in  addition  to  the  various  works  upon 
Anatomy,  and  Mr.  Wharton  Jones'  Eosay  in  the  Cyclop»dia  of  Anatomy  and  Physiology, 
the  recently  published  paper  by  Mr.  Toynbee  "  On  the  Functions  of  the  Muscles  of  the 
Tympanum  in  the  Human  Ear,"  in  the  British  and  Foreign  Medlco-ChiruTgical  Review 
for  January,  1868. 


completed  by  fibrous  membrane,  through  which  the  tenaor  tympani 
muscle  plays.  The  length  of  the  bony  portion  of  the  Eustachian  tabe 
is  about  half  an  inch,  and  of  an  irregular  elliptical  figure,  sometimfla 
resembling  a  mere  slit,  and  seldom  admitting,  even  in  the  dry 
bone,  anything  larger  than  an  ordinary-sized  dressing  probe»  and 
certainly  not  capable  of  giving  transit  to  the  great  majority  of  the 
bougies  and  other  instruments  recommended  by  aurists  to  be  passed 
through  it  for  the  purpose  of  clearing  it,  or  of  exploring  (  ?)  the 
cavitas  tympani. 

The  parts  contained  within  the  tympanum  are : — the  oesicala 
auditus,  the  muscles  by  which  these  bones  are  moved,  and  the 
chorda  tympani  nerve,  which  in  its  circuitous  course  traverses  the 
upper  part  of  this  cavity. 

This  chain  of  small  bones  has  three  points  of  attachment, — the 
membrana  tympani,  and  the  fenestra  ovalis,  between  which  they 
stretch,  and  the  walls  of  the  tympanum,  which  afford  them  sup- 
port. They  consist  of  the  malleus  or  hammer,  the  incus  or  anvil, 
and  the  stapes  or  stirrup ;  to  which  some  anatomists  have  added 
a  fourth  bone,  under  the  name  of  the  orbicular,  but  which 
is  now  believed  to  be  a  portion  of  the  incus.  All  these  bcmes, 
when  placed  together,  form  an  arched  chain  of  levers,  extending 
across  the  upper  and  back  portion  of  the  tympanal  cavity,  and 
which  by  their  motions  serve  to  convey  vibrations  of  sound  from 
the  membrana  tympani,  to  which  they  are  attached  externally, 
to  the  fenestra  ovalis,  where  the  inner  leg  of  the  arch  is  fastened; 
and  also  to  place  both  the  membrana  tympani  and  the  membrane 
of  the  fenestra  rotunda  in  particular  states  of  tension  or  relax- 
ation, whereby  they  can  be  affected  by  sounds  more  or  less 
grave  or  acute.  For  this  latter  purpose  their  mechanism  is  under 
the  control  of  muscles  probably  of  the  voluntary  class.  The  mal- 
leus or  hammer  consists  of  a  body  fitted  into  a  corresponding  sur- 
face in  the  incus ;  a  head  rising  into  the  tympanic  sinus  above 
the  attachment  of  the  membrana  tympani ;  a  manubrium  or  han- 
dle stretching  down  between  the  laminae  of  the  latter  structure, 
to  which  it  gives  insertion  and  support,  as  already  explained  at 
page  215  ;  a  tubercle  between  the  body  or  neck  and  handle, 
which  is  always  recognisable  through  the   membrana  tympam; 


and  a  long  slender  process,  which,  springing  at  a  right  angle  from 
the  rest  of  the  bone,  crosses  the  tympanal  cavity  obliquely  from 
behind  forwards,  and  a  little  downwards  towards  the  Glasserian 
fissure,  where  it  is  attached  near  the  edge  of  the  tympanic  ring. 
The  incus  is  also  an  irregularly-shaped  bone,  not  inaptly  resem* 
bling  a  bicuspid  tooth;  the  crown  of  which  is  articulated  to  a 
corresponding  surface  upon  the  malleus,  and  the  two  fangs  or 
crura  are  attached,  the  shorter  by  ligament  to  the  roof  of  the 
tympanum  near  the  orifice  of  the  mastoid  cells,  and  the  long 
process,  extending  downwards  nearly  parallel  with  the  handle  of 
the  malleus,  but  towards  the  inner  wall  of  the  tympanum  is  arti- 
culated with  the  head  of  the  stapes.  The  stapes  itself,  which  in 
its  similitude  to  a  stirrup  is  perhaps  the  most  exact  resemblance 
which  any  portion  of  anatomy  has  yet  derived  a  name  from,  is 
set  by  its  base  into  the  opening  of  the  vestibule,  and  thus  com- 
pletes the  connecting  links  between  the  external  and  internal  ears. 
From  the  anatomical  relations  of  this  bone,  and  its  acting  either 
with  an  intervening  membrane — the  membrana  vestibuli  of  for- 
mer anatomists— or  simply  by  ligamentous  connexions  to  the  edge 
of  the  foramen  ovalis,  as  the  principal  barrier  to  the  escape  of  the 
contents  of  the  vestibuli,  the  semicircular  canals,  and  even  the 
cochlea,  its  total  destruction  or  removal  must  be  attended  with 
irreparable  loss  of  hearing,  unless  the  foramen  ovalis  becomes  filled 
up  with  a  new  or  false  membrane,  and  that  the  labyrinthine  fluid 
re-accumulates.  Fortunately,  this  little  bone  is  less  frequently  lost 
in  otorrhoea  than  either  of  the  others.  The  various  articular  sur- 
faces between  these  minute  bones  are  incrusted  with  cartilages, 
provided  with  synovial  membranes,  and  held  together  by  minute 

The  muscles  which  move  these  small  bones  are  the  tensor 
tympani  and  the  stapedius ;  the  former  of  which  arises  in  the  osseo- 

*  It  is  said  that  at  birth  the  ossicles  are  as  large  as  in  the  adolt  The  stapes,  sajt 
Mr.  Williams,  **  weighs,  when  dried,  one  thirty-second  of  a  grain."  This  is  a  great  exag- 
geration. I  find  that  from  fire  to  six  of  these  little  bones  weigh,  in  the  diy  state,  a  grain. 
The  same  author,  in  that  Treatise  for  whidi  the  Umyersity  of  Edinburgh  awarded  a  gold 
medal,  states  that  "  the  membrana  tympani  ia  covered  with  wax,  which  is  for  the  pur- 
pose of  modifying  sound"  I ! 

816  AVAToinr  of  the  cavitas  tthpavi. 

cartilaginous  canal  above  the  Eustachian  tube  already  deacribed, 
and,  crossing  the  upper  portion  of  the  tympanum,  is  attached  to  the 
malleus  near  the  junction  of  the  tubercle  and  handle,  which  bone 
it  draws  inwards  and  forwards,  and  so  assists  to  render  the  mem- 
brane, which  it  supports,  concave  externally;  but  whether  that 
structure  is  really  rendered  more  tense  or  more  relaxed  by  this 
action,  remains  for  further  investigation.  It  would  appear  from 
observing  the  mechanism  of  the  chain  of  bones  extending  between 
the  external  and  internal  walls  of  the  tympanum,  that  the  actioo 
of  the  tensor  tympani  must,  by  drawing  the  malleus  inwards,  af- 
fect the  position  and  motions  of  the  stapes  upon  or  within  the 
fenestra  ovalis.  If,  as  anatomists  suppose,  the  action  of  the  ten- 
sor tympani  assists  indirectly  to  press  the  base  of  the  stapes  in- 
wards towards  the  cavity  of  the  vestibule,  it  is  manifest  that  it 
must  affect  the  fluid  of  the  labyrinth,  and  by  its  means  press  out- 
wards the  membrane  of  the  fenestra  rotunda.  But  if  the  long 
leg  of  the  incus,  through  which  the  motion  of  the  tensor  tympani 
is  conveyed  to  the  top  of  the  stapes  (instead  of  pressing  point- 
blank  against  that  bone  in  its  ordinary  horizontal  position,  so  as  to 
bear  upon  it  like  the  piston  rod  of  a  cylinder),  presses  it  obliquely, 
and  gives  its  base  an  oscillatory  motion,  it  is  as  likely  to  relax 
the  membrane  of  the  fenestra  rotunda  by  withdrawing  the  pressure 
of  a  portion  of  the  stapes  from  the  fenestra  ovalis.  And  die  ob- 
lique position  at  which  the  incus  articulates  with  the  stapes 
renders  this  probable ;  so  that  it  is  only  by  a  combined  action  of 
the  tensor  tympani  and  stapedius  muscles  that  the  base  of  the 
stapes  can  be  pressed  directly  inwards  against  the  fluid  of  the 
vestibule.  The  stapedius  muscle,  which  is  much  shorter  and 
smaller  than  the  preceding,  arises  within  the  aperture  of  the  py« 
ramid,  and  is  inserted  into  the  head  of  the  stapes.  By  some  it  is 
supposed  to  act  as  an  antagonist  to  the  tensor  tympani;  and 
this  opinion  receives  support  from  the  fact,  that  it  is  supplied  by 
a  branch  from  the  facial  nerve,  while  the  latter  receives  its  ner- 
vous supply  from  the  otic  ganglion ;  but,  says  Mr.  Wharton  Jones, 
**  the  principal  nerve  of  the  tensor  tympani  is  derived  from  the 
pterygoid  nerve  of  the  third  branch  of  the  fifth."  Its  action  is 
to  draw  the  stapes  backwards,  and  consequently  elevate  that  por- 


tion  of  its  base  contained  within  the  anterior  edge  of  the  fenestra 
ovalis.  It  is  remarkable,  that  both  these  muscles  have  their  ori- 
gin within  fine  bony  canals  which,  projecting  somewhat  into  the 
tympanal  cavity,  serve  to  give  them  an  exact  and  special  di- 
rection ;  and,  as  particularly  occurs  in  the  case  of  the  tensor  tym- 
pani,  by  means  of  pulley-like  tendons,  slightly  to  alter  the  ori- 
ginal direction  of  their  course.  Both  muscles  acting  together,  the 
tensor  tympani,  by  pressing  the  anterior  edge  of  the  base  of  the 
stapes,  and  the  stapedius  its  posterior  extremity,  must  press  it  in- 
wards, and  so  affect  the  fluid  of  the  labyrinth  and  the  membrane 
of  the  fenestra  rotunda. 

The  action  of  these  bones  and  muscles  is  twofold — when  vi- 
brations of  sound  impinge  on  the  mem  brana  tympani  to  convey  its 
minutest  motion  across  the  tympanum,  and  communicate  such 
to  the  labyrinth ;  and  also  to  act  as  the  analogue  of  the  iris,  and 
thus,  by  regulating  the  state  of  tension  of  the  different  structures 
thrown  into  vibration,  to  control  the  amount  of  sonorous  undula- 
tions that  pass  to  the  labyrinth.  With  respect  to  the  problem 
regarding  the  voluntary  action  of  the  tympanic  muscles,  Mr. 
BUcher  writes :  as  they  **  are  supplied  from  the  two  sources, — from 
the  voluntary  system  by  the  portio  dura,  and  from  the  ganglionic 
by  the  chorda  tympani  and  the  otic  ganglion, — is  it  not  probable 
that  they  may  be  of  a  mixed  character,  acting  involuntarily  when 
the  acoustic  nerve  is  over-excited,  or  when  the  mind  is  otherwise 
engaged,  and  attention  not  directed  to  the  protection  of  the  mem- 
brane and  of  the  ear  in  general ;  and  being  influenced  by  voli- 
tion, when  the  individual  is  desirous  to  increase  or  to  diminish 
his  mental  perceptions?**  Mr.  Toynbee,  who  has  lately  written  an 
ingenious  article  upon  the  subject  (see  Note,  page  313),  says: 
'^  I  think  it  may  be  fairly  inferred,  that  the  function  of  the  tensor 
tympani  muscles  is  to  protect  the  membrana  tympani  and  the 
labyrinth  from  injury  during  loud  sounds ;  while  the  stapedius 
muscle  places  these  structures  in  a  position  to  be  impressed  by 
the  most  delicate  vibrations;  and  it  would  appear  to  be  brought 
into  action  during  the  process  of  listening.** 

The  Vidian  nerve,  after  leaving  the  portio  dura  near  its  exit 
from  the  aqueduct  of  Fallopius,  enters  the  tympanum,  where  it 

318  AVATomr  of  thb  mastoid  cxlu. 

leceiTee  the  name  of  chorda  tympani,  by  a  special  opening  behind 
the  posterior  margin  of  the  tympanic  groove,  and  forming  an  arch 
close  to  the  roof  of  the  cavity,  runs  to  the  canal  beside  the  fissure 
of  Glasser ;  passing  in  this  course  between  the  handle  of  the  mal- 
leus in  front  and  the  long  process  of  the  incus  behind.  In  expltr 
nation  of  the  peculiar  tortuous  course  of  this  most  remarkaUe 
nerve,  and  its  final  association  with  the  gustatory,  submaxillaiy, 
and  dental  supply.  Professor  Harrison  says: — ^This  connexion, 
also,  so  close  to  the  tympanum,  which  contains  the  ossicula  and 
musculi  auditus,  may  be  designed  to  impart  the  twofold  proper^ 
ties  of  sensation  and  of  motion  to  this  apparatus,  through  the  fila- 
ments which  connect  the  portio  dura  subsequently  to  the  tympanic 
plexus:  thus  the  organ  of  hearing,  like  that  of  vision,  will  befiir- 
nished  with  the  three  sets  of  nerves,  one  for  special  sense,  one  for 
sensation,  and  one  for  motion.**  (Dublin  Dissector.)  A  familiar 
example  of  one  of  the  phenomena  resulting  from  the  course  of  this 
curious  nerve  is,  that  of  having  the  teeth  *''  set  on  edge**  on  hear- 
ing the  filing  of  a  saw,  or  any  other  similar  grating  sound* 

The  mastoid  cells  are  so  irregular  both  in  size,  number,  and 
arrangement,  that  no  special  description  of  them  can  be  givim; 
those  nearest  the  tympanum,  one  or  two  in  particular,  are  the 
largest;  in  a  pathological  point  of  view,  it  is  sufiicient  to  know 
that  they  communicate  freely  with  the  cavitas  tympani,  and  are 
lined  by  a  continuation  of  its  investing  membrane;  they  also  sur- 
round the  floor  as  well  as  the  posterior  wall  of  the  tympanum ;  and 
the  former  locality  is  frequently  seen  covered  with  small  cells  in 
the  dried  bone.  One  of  the  best  methods  of  displaying  the  form 
and  continuity  of  these  cells  is  by  a  cast  taken  in  type  metal,  when 
they  resemble  a  bunch  of  grapes  attached  by  the  stalk  to  the  por- 
tion filling  the  tympanum.  Anatomists  and  physiologists  have 
not  yet  offered  an  unobjectionable  theory  to  account  for  the  ex- 
istence of  the  mastoid  cells,  which  are  only  developed  in  adult 
life.  The  generally  received  opinion  is,  that  they  permit  a 
greater  degree  of  resonance  in  the  cavity  of  the  tympanum  than 
would  otherwise  occur.  It  has  been  advanced  that,  by  afford- 
ing a  greater  amount  of  surface  for  the  expansion  of  the  mu- 
cous membrane  of  the  tympanic  cavity,  like  the  Schneiderian 


membrane  in  the  ethmoid  cells  and  frontal  sinuses,  they  thereby 
increase  the  powers  of  hearing;  but  we  have  no  warrant  for  be- 
lieving that  the  membrane  is  endowed  with  that  faculty.  I  am 
inclined  to  think  that,  independent  of  their  mechanical  use  in 
affording  lightness  with  stability  to  the  mastoid  process,  they  act 
as  a  diverticulum  or  reservoir  for  the  air  contained  in  the  tympa* 
nic  cavity ;  and  their  being  placed  nearly  opposite  the  entrance 
of  the  Eustachian  tube  rather  favours  this  idea.  If  there  was 
not  some  such  space  in  which  air  might  be  occasionally  compressed, 
I  believe  the  membrane  would  be  ruptured  in  forcible  expirations, 
— such  as  sneezing,  coughing,  or  violently  blowing  the  nose, — as 
well  as  sudden  loud  noises  acting  from  without,  much  more  fre- 
quently than  usually  occurs.  And,  when  the  membrane  bursts 
during  the  progress  of  otitis  (which  generally  occurs  during  a  vio- 
lent expiration),  it  must  be  remembered  that  the  mastoid  cells  are 
either  blocked  up  by  the  inflammatory  process  or  filled  with  pus. 
The  Eustachian  tube  consists  of  an  osseous  and  a  cartilaginous 
portion ;  the  average  length  of  the  former  is  about  half  an  inch, 
in  width  it  is  about  the  eighth  of  an  inch  from  above  downwards, 
and  not  more  than  the  tenth  from  before  backwards,  or  from  side 
to  side.  This  tube  is  separated  from  the  carotid  canal  by  a  very 
thin  plate  of  bone.  The  membrano-cartilaginous  portion  is  fully 
an  inch  long ;  it  is  attached  to  the  notched  irregular  extremity  of 
the  osseous  part  in  the  petrous  portion  of  the  temporal  bone,  and 
also  to  the  edge  of  the  sphenoid.  This  is  generally  the  narrowest 
part  of  the  tube,  and  from  thence  in  its  downward  and  inward  di- 
rection to  its  gutteral  orifice  in  the  pharynx  it  gradually  enlarges, 
but  more  particularly  at  its  lower  extremity.  It  thus  resembles  a 
straight  trumpet,  the  small  enlargement  of  the  mouth-piece  being 
at  the  tympanum,  and  the  larger  bell-shaped  extremity  opening 
behind  the  posterior  nares,  with  its  lower  margin  a  little  below 
the  floor  of  that  aperture.  Viewed  in  the  recent  state,  by  mak- 
ing a  central  vertical  section  through  the  base  of  the  skull, 
mouth,  and  pharynx,  the  lower  opening  of  the  Eustachian  tube 
presents  an  obliquely  upright  elliptical  slit  or  fissure  about  half 
an  inch  long,  with  thick,  round,  and  slightly  prominent  lips. 
Placed  thus  behind,  and  so  much  above  the  hard  and  soft  palate. 

820  AVATomr  of  thb  cayitis  ttmpavi. 

it  is  manifest  that  the  tonsils,  even  when  enlarged,  cannot  press 
upon  its  partially  open  mouth  without  first  coming  in  contact 
with  the  palate  plate,  and  lifting  upwards  and  backwards  the  ve- 
lum, which,  it  is  well  known,  never  occurs.  When  the  tonsils  are 
in  a  state  of  chronic  enlargement  from  hypertrophy  of  their  folli- 
cles, thickening  of  their  mucous  membrane,  and  cheesy,  calcareouSi 
or  other  abnormal  deposits  within  their  structure, — they  first  pro- 
ject towards  one  another,  and  consequently  encroach  upon  the 
size  and  shape  of  the  isthmus  faucium,  then  towards  the  cavity  ct 
the  mouth,  and  afterwards  into  the  bag  of  the  pharynx.     1  have 
never  seen  nor  heard  of  a  preparation  showing  the  greatest  possi- 
ble degree  of  enlargement  of  the  tonsil,  in  which  it  pressed  upon 
the  trumpet-mouth  of  the  Eustachian  tube.     Anatomists  will, 
therefore,  find  it  as  difficult  to  believe  that  enlarged  tonsils  pro- 
duce deafness  as  practical  surgeons  to  believe  that  their  removal 
can  in  any  way  relieve  loss  of  hearing.     Even  in  cases  of  cynan- 
che  tonsillaris,  when  so  large  a  collection  of  matter  forms  in  the 
gland  that  suffocation  threatens,  there  is  no  deafness.  When  deaf- 
ness coexists  with  enlarged  tonsils,  I  believe  it  is  produced  by  the 
thickening  of  the  mucous  membrane  extending  into  the  Eusta- 
chian tube,  or  into  the  tympanum.  The  direction  of  the  Eustachian 
tube  is  forwards,  inwards,  and  downwards,  towards  its  fellow  on 
the  opposite  side,  so  that  if  a  line  passing  through  the  centre  of 
each  was  prolonged,  it  would  cross  that  of  the  other  side  at  an 
acute  angle  about  the  middle  of  the  palate  bone.     It  is  partially 
fixed  by  the  hamular  process  and  the  levator  palati  muscle ;  and 
its  connexions  with  the  muscles  of  the  pharynx  must  always  ren- 
der it  liable  to  alteration  in  the  acts  of  mastication,  deglutition, 
coughing,  sneezing,  or  yawning.     It  must  not  be  supposed  that 
the  Eustachian  is  a  tube  always  open,  no  more  than  the  urethra; 
although  provided  with  cartilage,  its  sides  are,  in  the  middle  third 
of  its  course  at  least,  usually  in  contact. 

The  great  gastro-pulmonary  mucous  membrane,  passing  up  over 
the  nose  and  pharynx,  is  continued  into  the  Eustachian  tube,  at 
the  orifice  of  which  it  presents  the  same  characters  with  that  lin- 
ing the  mouth  and  throat,  being  highly  vascular,  and  studded 
with  numerous  fine  glands,  which  secrete  a  plentiful  supply  of  the 


usual  fluid  poured  out  from  that  structure ;  and  we  can,  therefore, 
understand  how  affections  of  these  membranes  may,  by  continuity 
of  surface,  extend  into  the  upper  portion  of  the  tube  and  middle 
ear.  As  the  membrane  advances  towards  the  osseous  part  of  the 
tube,  where  it  becomes  periosteal  and  fibro-mucous,  its  characters 
change :  it  is  less  red,  presents  fewer  follicles,  is  remarkably  fine ; 
and  the  villi  on  its  surface  are  supposed  to  possess  that  peculiar  vibra- 
tory motion  which  Purkinjie  and  Valentin  discovered  some  years 
ago.  As  it  approaches  the  upper  extremity  of  the  tube  it  becomes 
still  more  pale  and  delicate  until  it  enters  the  cavity  of  the  tym- 
panum, in  the  healthy  normal  state  of  which  it  is  of  such  smooth- 
ness and  tenacity  as  to  be  demonstrated  with  difficulty ;  yet  in 
disease  or  by  exposure,  as  every  practical  aural  surgeon  knows, 
it  becomes  in  succession  highly  vascular,  villous,  thickened,  infil- 
trated, pulpy,  and  even  sarcomatous,  bleeding  freely,  secreting 
mucus  largely,  sometimes  pouring  out  pus  in  an  incredibly  short 
space  of  time,  and  throwing  out  fungous  granulations,  &c.  In  the 
cavity  of  the  tympanum  it  spreads  over  every  surface,  and  is  re- 
flected round  the  various  bones,  ligaments,  muscles,  and  nerves, 
and  over  the  membranes  closing  the  external  auditory  and  cochlear 
apertures ;  and  also  extends  into  the  large  series  of  mastoid  cells ; 
so  that,  like  the  superficies  of  the  peritoneum,  it  presents,  on  a 
careful  consideration  and  examination  of  the  parts,  a  much  more 
extensive  surface  than  would,  at  a  superficial  glance,  appear.  In 
anatomical  characters,  as  well  as  in  pathological  phenomena,  the 
lining  of  the  lachrymal  passage  has  many  points  of  analogy  with 
the  tympano-Eustachian  mucous  membrane,  which  those  fami- 
liar with  the  structure,  relations,  and  diseases  of  both  will  upon 
reflection  perceive,  and  may  in  treatment  follow  out.  In  the  nor- 
mal state  the  lining  of  the  tympanic  cavity  presents  a  smooth,  dry, 
but  polished  surface,  of  a  greyish-white  colour,  somewhat  like  the 
external  aspect  of  the  membrana  tympani,  but  frequently  present- 
ing, as  9k post-mortem  appearance,  a  slightly  pinkish  hue:  being  in 
a  healthy  state  transparent,  its  colour  must  be  that  of  the  bone 
beneath.  Like  all  mucous  surfaces,  it  exhales  moisture,  but  the 
quantity  must  be  so  slight,  and  the  fluid  so  very  fine,  that  it  finds 
a  ready  outlet  through  the  Eustachian  tube.  In  the  fcBtus  the  mem- 



brane  is  highly  vascular  and  secretes  mucus^  which  is  often  found 
filling  up  the  tympanum.  Perhaps  the  variety  in  the  period  of  au- 
dition may  depend  upon  the  more  or  less  rapid  absorption  or  excre- 
tion through  the  Eustachian  tube  of  this  mucus;  while  its  presence 
in  the*  very  early  periods  of  life  may  be  useful  in  protecting  the  in- 
ternal ear  and  auditory  nerve  from  the  injurious  influences  of 
sound  in  their  then  delicate  condition,  —  in  the  same  manner 
as  the  closed  eye-lids  of  cats  and  some  other  animals  for  the  first 
eight  or  nine  days  after  birth  protect  them  from  the  injurions 
effects  of  light. 

I  have  thought  that  the  increase  of  the  lower  jaw  at  the  period 
of  the  first  dentition  (the  usual  time  when  infants  are  first  attracted 
by  sounds),  by  its  condyle  pressing  on  the  cavity  which  forms  the 
lower  boundary  or  floor  of  the  tympanum,  serving  to  enlarge  it  by 
pressing  upwards  and  outwards  the  tympanic  ring»  and  also  by  the 
development  of  the  dental  organs  not  only  altering  the  position 
of  the  maxilla  itself,  but  calling  into  action  a  hitherto  but  Kttlc 
employed  set  of  muscles, — might  so  change  the  position  and  cali- 
ber of  the  inferior  portion  of  the  Eustachian  tube  as  to  aflTord  a 
ready  outlet  for  the  contents  of  the  tympanum.  In  support  of  this 
view,  I  may  mention  that,  in  many  cases  of  partial  deafness,  as  well 
as  defective  speech,  and  in  some  instances  of  stammering,  there  is 
not  only  a  great  delay  in  the  usual  hearing  period  at  infancy,  but 
a  very  peculiar  formation  of  mouth.  In  many  of  those  cases  which 
I  have  examined,  the  palate  plate  was  remarkably  high  and  narrow 
behind  the  incisors,  which,  as  well  as  several  of  the  other  teeth, 
were  irregular,  and  had  been  slowly  and  with  difficulty  developed.* 

This  lining  membrane  of  the  middle  ear  is  highly  endowed 
with  nerves  from  the  fifth,  the  portio  dura  of  the  seventh,  and  the 
nervus  anastomosis  of  Jacobson, — known  as  the  tympanic  plexus, 
formed  between  the  Vidian,  glosso-pharyngeal,  twigs  from  the  otic 
ganglion  of  Arnold,  and  the  sympathetic, — which  lies,  as  already 
stated,  on  the  inner  wall  of  the  tympanum.  In  a  healthj  state 
I  do  not  think  this  mucous  lining  is  so  exquisitely  sensitive  as  the 
membrana  tympani.     The  cavitas  tympani  is  as  largely  supplied 

*  With  respect  to  the  period  of  audition,  see  the  chapter  on  the  Internal  Ear,  and  alao 
that  on  Deaf-dombneia. 


with  blood-vessels  as  the  membrana  tyrapani,  already  described 
and  figured  at  page  216,  and  derived  from  nearly  the  same  sources, 
—  the  stylo-mastoid  from  the  posterior  auricular,  which  enters 
through  the  hiatus  of  Fallopius,  and  branches  from  the  temporal, 
internal  maxillary, middle  meningeal,  and  the  internal  carotid.  The 
pathological  conditions  which  the  cavitas  tympani  presents  in  the 
dead  subject  are  related  at  page  111 ;  and  the  abnormal  states  of 
that  space  during  life,  and  also  the  conditions  of  the  middle  ear  and 
Eustachian  tube,  are  exhibited  in  the  Registry  of  Cases. 


As  modem  anatomists  have  paid  particular  attention  to  the 
primitive  formation  of  the  cavity  of  the  tympanum,  many  of  the 
congenital  malformations  which  it  presents  are  explained  upon  the 
principle  of  arrest  of  development.  As  already  stated,  the  cavity  of 
the  tympanum  may  be  absent,  its  site  consisting  of  solid  bone ;  it  has 
also  been  found  much  smaller  than  natural,  showing  a  persistence  of 
the  characters  observed  during  festal  life.  Its  fenestras  are  at  times 
but  rudimentary,  closed  by  bony  matter,  or  altogether  absent ;  and 
the  cavity  has  been  found  filled  with  morbid  deposits.  The  ossi- 
cula  are  liable  to  great  iwiriety, — they  may  be  altogether  or  par- 
tially deficient;  when  the  stapes  is  wanting,  ossified  to  the  edge 
of  the  fenestra  ovalis,  or  disconnected  with  the  incus,  conside- 
rable impairment  of  hearing  must  follow.  But,  in  the  great 
majority  of  instances  in  which  malfoimations  to  any  amount  ex- 
isted in  the  cavitas  tympani  or  its  contents,  the  subjects  of  such 
were  either  infants  whose  state  of  audition  could  not  be  learned, 
or  persons  congenitally  deaf  and  dumb.  I  have  already  spoken 
of  the  irregularity  which  the  malleus,  as  seen  through  the  mem- 
brana tympani  occasionally  presents  in  some  deaf  mutes.  The 
Eustachian  tube  has  been  found  altogether  wanting  or  partially 


Considerable  hemorrhage  takes  place  from  the  ears,  and  pours 
out  of  the  external  meatus,  not  merely  incases  of  violent  mechani- 
cal injury,  and  from  the  vicinity  of  loud  or  unexpected  noises,  as 

z  2 

324  niJURiRs  OF  the  tympanum. 

already  explained  at  page  222,  but  in  cases  of  sudden  death  from 
strangulation  and  some  other  forms  of  asphyxia.     Bleeding  from 
the  ears,  as  well  as  the  nose,  mouth,  eyes,  and  genitals  usually  oc- 
curs in  hanging  as  a  public  execution,  but  not  always  when  it  is 
suicidal.     In  such  cases  it  is  believed  that  the  hemorrhages  are  the 
result  of  congestion ;  and  if  this  be  true,  that  from  the  ears 'most 
come  from  the  meatus  or  from  the  tympanal  cavity  through  a  rup- 
tured membrana  tympani.     Littre  found  the  membrana  tympani 
ruptured  in  a  case  of  strangulation ;  but,  as  I  already  stated  in  two 
previous  portions  of  this  work,  the  source  of  the  hemorrhage,  and 
the  cases  in  which  it  occurs,  either  as  a  constant  or  variable  symp- 
tom, have  not  yet  been  fully  investigated.     A  case  has  just  oc- 
curred in  this  city,  for  the  particulars  of  which,  as  well  as  the  use 
of  the  preparation  from  which  the  accompanying  illustration  was 
made,  I  am  much  indebted  to  Professor  Geoghegan.     A  female, 
aged  40,  strangled  herself,  by  twisting  a  ribbon  round  her  neck, 
during  the  present  month, — February,  1853.    She  was  discovered 
by  the  police  next  morning,  and  Professor  Geoghegan  made  a 
post-mortem  examination  of  the  body  a  few  hours    afterwards. 
The  face  and  lips  were  of  a  dusky  red,  but  unswollen,  and  blood 
poured  out  of  the  left  meatus.     It  is  sufficient  for  me  to  state 
the  particulars  of  the  examination  as  regards  the  ear,  which  was 
carefully  removed.    A  section  having  been  made  through  the  in- 
ternal ear,  it  exposed  the  cavity  of  the  tympanum,  which  was 
found  to  contain  a  very  little  bright  fluid  blood,  a  trace  of  which 
had  passed  for  some  distance  into  the  Eustachian  tube ;  the  mu- 
cous membrane  of  the  cavity  of  the  tympanum  did  not  seem  to 
be  congested,  but  was  partially  stained  with  the  blood  which 
lay  in  it.     The  membrana  tympani  presented  a  mottled  red  and 
semitransparent  appearance,  the  former  being  the  result  of  blood 
extra vasated  upon  its  surface  and  between  its  laminae.     Towards 
its  posterior  attachment,  a  little  behind  and  below  the  tubercle 
of  the  malleus,  the  membrane  was  red,  and  presented  the  trian- 
gular aperture  shown  in  the  accompanying  representation;  the 
anterior  inferior  angle  of  the  aperture  is  nearly  on  a  level  with 
the  end  of  the  manubrium,  and  the  posterior  margin  of  the  tri- 


angle  corresponds  with  the  insertion  of  the  membrane  into  the  tym- 
panic ring;  but  the  rent  does  not  run  quite  into  it.  Owing  to 
the  rupture  of  the  radiating  fibres — which  are  na-  f^''^.'^'^Z>s 
turally  feeble  at  this  point, — the  handle  of  the  mal-  U 
leusis  drawn  somewhat  forwards  and  upwards  from 
its  natural  position.  In  the  preparation,  the  chorda 
tympani  nerve  is  plainly  seen  upon  the  inside  bounding  the  upper 
angle  of  the  aperture,  which  rather  curves  inwards  towards  the 
malleus,  leaving  a  small  portion  of  membrane  above  and  behind 
it,  while  the  posterior  angle  of  the  rent  runs  nearly  into  the  tym- 
panic ring.  The  tensor  tympani  muscle  preserves  its  attachment 
to  the  malleus.  The  inner  wall  of  the  tympanic  cavity  having  been, 
in  great  part,  removed,  as  well  as  the  other  ossicula,  I  am  unable 
to  state  what  the  condition  of  these  parts  was ;  but  the  section  of 
the  labyrinth  does  not  exhibit  any  vascularity  or  extravasation, 
and  all  that  portion  of  the  mucous  lining  of  the  tympanic  opening 
of  the  Eustachian  tube,  and  as  much  of  the  cavitas  tympani  as  re- 
mains, present  no  congestion  or  extravasation. 

From  an  examination  of  this  unique  and  most  valuable  speci- 
men, two  questions  arise, — how  did  the  rupture  occur,  and  from 
whence  did  the  hemorrhage  come  ?  By  reference  to  page  139,  as 
well  as  an  examination  of  the  Registry,  given  in  chapter  iii.,  it 
will  be  seen  that  the  aperture  in  the  membrane  has  taken  place  in 
the  second  most  usual  locality, — viz.,  at  the  posterior  margin  of 
its  attachment,  behind  the  malleus,  and  immediately  below  and 
in  front  of  the  opening  of  the  mastoid  cells, — where  a  stream  of 
air,  if  forcibly  injected  through  the  Eustachian  tube,  would 
chiefly  impinge,  particularly  if  the  mastoid  cells  were  already 
filled.  That  this  jet  of  air  would,  when  the  membrane  is  in  a 
high  state  of  tension,  produce  the  rupture,  I  have  no  doubt; 
but  how  caused  during  the  death-struggle  in  strangulation,  and 
with  the  mouth  and  nose  open,  I  cannot  explain.  It  is  remarka- 
ble, however,  that  in  this  case  the  rent  occurs  in  the  precise  loca- 
lity where  I  described  a  cicatrix  in  the  case  of  an  artillery-man  who 
had  had  hemorrhage  from  the  ear.  (See  page  222.)  With  regard 
to  the  source  of  the  hemorrhage,  I  am  inclined  to  suppose  that  it 
came  from  the  large  branches  of  the  stylo-mastoid  artery  which  de- 

326  nrjDRiEs  of  the  tticpahum. 

Bcend  along  the  handle  of  the  malleus  through  the  exact  space 
traversed  by  the  rent,  as  shown  in  the  illustration  at  page  216. 
This  being  the  case,  we  may  suppose  that  the  rupture  was  the 
original  cause,  and  the  hemorrhage  a  secondary  consequence.  The 
only  two  cases  on  record  in  which  there  has  been  a  careful  exami- 
nation of  the  parts,  is  that  by  Littre  and  the  foregoing.* 

Bleeding  occurs  from  the  ears  occasionally  during  violent  pa- 
roxysms of  hooping  cough, — a  fact  corroborative  of  the  belief, 
that  the  source  of  the  hemorrhage  is  from  a  ruptured  tympanal 
membrane.  I  believe  sailors  do  not  suffer  from  cannon-firing  like 
artillery-men ;  this  may  arise  from  the  floating  substance  on  which 
they  stand,  and  also  from  the  muzzle  of  the  gun  being  separated 
from  them  by  the  side  of  the  ship. 

Whenever  the  membrana  tympani  is  pierced  or  ruptured  by 
external  violence,  the  cavity  of  the  tympanum  must  be  more  or 
less  injured,  and  the  extent  of  mischief  will  much  depend  upon 
the  nature  of  the  penetrating  instrument  or  foreign  substance  in- 
troduced ;  yet  the  results  are  not  always  what  might  be  expected 
from  the  nature  of  the  injury,  as  a  piece  of  slate  pencil  may 
be  driven  into  the  tympanum,  and  inflammation  and  suppura- 
tion alone  follow ;  whereas,  a  needle  passing  beyond  the  membrana 
tympani  has  caused  death ;  and  an  irritating  foreign  substance  is 
said  to  have  induced  epilepsy.  Dr.  Maclagan  has  recorded  **  the 
history  of  a  case  of  epilepsy  and  deafness  depending  on  the  pre- 
sence of  a  foreign  body  in  the  ear.  The  patient,  when  a  boy 
about  five  years  of  age,  had  introduced  into  his  ear  what  was  sup- 
posed to  be  the  seed  of  a  sycamore.  Unsuccessful  attempts  were 
made  at  the  time  to  extract  it.  It  remained  in  the  ear  four  years 
without  giving  rise  to  any  uneasiness,  at  which  period  the  patient, 
then  nearly  ten  years  old,  was  seized  with  epilepsy  of  a  marked 
character.  Deafness,  which  had  hitherto  been  slight,  increased, 
and  the  epilepsy  and  deafness  continued  in  an  aggravated  form 
for  six  years  more,  or  ten  years  from  the  introduction  of  the  fo* 

*  On  the  subject  of  hemorrhage  from  the  ears,  as  a  sign  of  certain  forms  of  death, 
such  as  the  foregoing  instance,  I  would  also  refer  my  readers  to  the  able  tract,  by  Pnife»- 
Bor  Geoghegan^  "  An  Examination  of  the  Medical  Facts  in  the  Case  of  the  Queea  «.  W. 
B.  Kirwan."     Dublin  :  Fannin  and  Co.     1853. 


reign  body.  It  was  at  this  period  that  Dr.  Maclagan  was  con- 
sulted for  the  deafness ;  and  he  succeeded  in  removing  from  the 
ear  the  seed,  surrounded  by  a  nodule  of  wax  sufficiently  large  to 
fill  up  the  whole  meatus.  Under  the  ordinary  treatment  the  deaf- 
ness declined;  and,  since  that  period  (then  twenty  years),  he  had 
no  return  of  the  epilepsy."  Such  is  the  record  of  this  remarkable 
case,  as  communicated  to  the  Edinburgh  Medico-Chirurgical  So- 
ciety, and  published  in  the  Monthly  Journal  for  February,  1841. 
Giving  the  author  full  credit  for  his  implicit  belief  in  the  case,  I 
must  confess  that  I  am  inclined  to  bring  in  the  Scotch  verdict  of 
*^  non  proven,**  so  far  as  the  seed  is  concerned.  The  state  of  the  ear, 
either  before  or  after  the  removal  of  the  foreign  body,  has  not  been 
recorded ;  nor  whether  the  seed  ruptured  the  membrana  tyrapani,or 
caused  any  disorganization  of  the  parts ;  neither  was  the  cause  of 
the  deafness  explained  in  any  way.  If  the  introduction  of  a  fo- 
reign body  into  the  meatus  produces  epilepsy,  I  believe  it  must 
be  by  irritating  or  pressing  upon  that  highly  sensitive  portion  of 
the  meatus,  to  which  I  have  already  referred  at  pp.  77  and  189, 
and  the  slightest  touch  of  which  will,  in  some  persons,  induce  vio- 
lent spasmodic  coughing,  evidently  from  irritation  of  the  larynx. 
Now,  according  to  the  recent  discoveries  of  Dr.  Marshall  Hall,  the 
immediate  cause  of  epilepsy  is,  in  many  cases,  spasm  of  the  glot- 
tis ;  and  I  think  it  possible  that  such  may  have  occurred  in  the 
instance  just  referred  to.*  Those  observations  which  I  made  at 
page  178,  upon  the  removal  of  foreign  bodies  from  the  meatus, 
are  equally  applicable  to  the  present  subject ;  and  still  greater 
caution  should  be  observed  with  respect  to  the  method  of  explo- 
ration, and  the  endeavours  made  to  extract  foreign  substances 
without  having  such  brought  fairly  into  view.  Cases  have  been 
recorded,  both  at  home  and  abroad,  in  which  violent  efforts  made  by 
surgeons  to  remove  extraneous  bodies,  said  to  have  been  introduced 
into  the  tympanum,  have  proved  fatal.  Nitric  acid  poured  into  the 
ear  has  caused  death,f  apparently  from  inflammation  extending  to 
the  brain  and  its  membranes  through  the  meatus  intemus. 

*  I  am  much  indebted  to  Dr.  Douglas  Maclagan  for  having,  in  addition  to  the  above 
printed  statement,  placed  his  father's  original  MS.  of  the  case  at  my  disposal 

t  See  a  case  related  by  Dr.  Morrison,  of  Newry,  in  the  Dublin  Journal  of  Medical 
Science  for  March,  1836. 

838  iHJirmiBS  of  the  rrifPAiruM. 

Independently  of  all  these  injuries  eontingent  upon 
applied  direotly  to  the  ear,  mischief  of  a  much  more  serious  na- 
ture may  result  from  fracture  of  the  base  of  the  skull,  or  fissure 
passing  through  the  petrous  portion  of  the  temporal  bone,  and, 
consequently,  the  middle  and  internal  ear.    In  such  a  case,  hemor- 
rhage from  the  ear  is  one  of  the  earliest  symptoms ;  yet,  of  itself^ 
it  is  not  a  proof  of  fracture,  as  it  may  arise  from  concussion,  but  it  is 
presumptive  evidence  of  the  former.     I  have  generally  remarked 
the  blood  particularly  thin  and  of  a  highly  florid  colour  in  these 
cases.     Subsequently,  in  cases  of  fracture,  a  clear  or  pale  straw- 
coloured  fluid  flows  out  of  the  ear  in  immense  quantities,  so  as  to 
saturate  the  bed  on  which  the  patient  lies.     My  esteemed  precep- 
tor, the  late  Abraham  Colles,  who  was  justly  considered  an  autho- 
rity upon  the  subject  of  injuries  of  the  head,  and  who,  in  the  early 
period  of  his  practice,  enjoyed  far  more  extensive  opportunities 
for  studying  these  affections  than  will,  I  am  happy  to  say,  ever 
be  again  afforded  in  this  country,*  entertained  the  opinion,  and 
taught  it  in  his  lectures,  that,  when  the  patient  lay  upon  the  un« 
affected  side,  this  serous  fluid  merely  "  welled  up  into  the  meatus,* 
but  never  overflowed  that  cavity.     Considerable  discussion  has 
arisen  as  to  the  cause  and  source  of  this  fluid.     By  some  it  has 
been  supposed,  that  it  was  the  serosity  of  the  effused  blood  pressed 
through  a  fissure  in  the  bone ;  by  others,  that  it  came  from  the 
cavity  of  the  cranium,  and  particularly  the  bag  of  the  arachnoid; 
while  many  have  held,  that  this  flux  is  the  liquor  Cotunnii.     The 

*  The  amount  of  injuries  of  the  head  received  into  the  Dublin  hotpitals  tixtj  or  m- 
▼enty  years  ago  was  quite  incredible  ;  as,  independent  of  the  ordinary  aoddents  wbidi 
must  occur  in  a  large  city,  two  special  causes,  neither  of  which  now  exist,  then  oondooed 
to  swell  their  numbers.  Tliose  who  have  read  Dease*s  book  npon  Injuries  of  tbe  HmmI  eamiot 
fUl  to  have  been  struck  with  the  circumstance  that,  in  the  eases  of  most  of  tbe  males  re- 
oorded,  the  injury  inflicted  was,  "  hit  with  a  hanger,*'  a  short,  heavy  sword  which  the  Dab- 
lin  police  and  several  of  the  tradespeople  of  that  period  carried,  and  which  they  appeur  to 
have  used  very  freely.  In  the  case  of  females,  the  violence  was  frequently  caused  by  having 
fkllen  out  of  a  window  in  the  endeavour  to  reach  the  end  of  a  stick  which  projected  there- 
from, like  a  bowsprit,  with  lines  on  each  side,  for  the  purpose  of  drying  clothes.  Thto  con- 
trivance may  still  be  seen  in  some  of  the  lanes  and  back  streets  of  the  Liberty.  My 
father,  who  had  been  a  pupil  of  Dease,  and  who  had  large  opportunities  of  treating  ft>ac- 
tnres  of  the  cranium  during  the  days  of  faction  fights  in  Ireland,  used  to  remai^,  that 
blood  flowing  from  the  ears,  though  a  bad  was  not  a  fatal  symptom,  but  the  **  weUin|: 
up"  of  serum  or  clear  fluid  was  always  fatal. 


subject  was  ably  treated  in  the  Archives  Ghierales  a  few  years  ago 
by  Messrs.  Chaissaignac  and  Robert,*  the  latter  of  whom  gives 
the  following  explanation  of  this  occurrence : — **  The  dura  mater 
becomes  very  thin  where  it  lines  the  internal  auditory  canal,  which 
it  docs  closely,  and  is  continued  in  the  form  of  a  sheath,  over  the 
facial,  and  the  two  branches  of  the  auditory  nerves,  as  they  leave 
the  cranium.  The  arachnoid  accompanies  the  dura  mater  to  the 
bottom  of  the  internal  auditory  canal,  and  is  then  reflected  upon 
the  nerves  of  the  seventh  pair  without  adhering  to  them,  as  at  the 
base  of  the  brain  itself.  But  the  seventh  pair  does  not  nearly  fill 
the  canal,  the  space  comprised  between  them  and  its  walls  is  filled 
with  cerebro-spinal  fluid,  which  is  known  to  be  very  abundant  at 
the  inferior  and  middle  portions  of  the  brain.  It  is  evident,  then, 
that,  if  the  dura  mater  and  the  two  contiguous  folds  of  the  arach- 
noid are  ruptured  at  the  base  of  the  internal  auditory  canal,  the 
cerebro-spinal  fluid  on  the  outside  of  the  arachnoid,  between  it 
and  the  nerves,  must  escape  freely  by  this  rupture.  We  may  con- 
ceive even  that  a  rupture  of  the  dura  mater  alone  would  be  suffi- 
cient for  the  same  effect,  if  this  took  place  at  the  very  bottom  of 
the  canal,  at  the  point  where  the  arachnoid  abandons  the  surface 
of  the  dura  mater  to  fold  upon  itself,  and  form  the  double  serous 
sheath  placed  round  the  seventh  pair,  and  the  cerebro-spinal  fluid 
immediately  surrounding  this.  Once  finding  its  way  through  the 
cerebral  membranes,  the  liquid  would  easily  get  beyond  the  fine 
osseous  plate  which  separates  the  bottom  of  the  internal  auditory 
canal  from  the  vestibule,  if  this  plate  is  fractured;  from  thence  it 
would  traverse  the  labyrinth,  and  reach  the  cavity  of  the  tympa- 
num, either  through  the  fissure  of  the  petrous  portion,  or  through 
the  fenestrum  ovale  itself,  which  is  found  open  and  free,  in  con- 
sequence of  the  displacement  which  the  stapes  has  undergone. 
Lastly,  from  the  cavity  of  the  middle  ear  the  liquid  would  flow 
freely  outwards  by  the  external  auditory  canal,  through  a  rupture 
which  always  occurs  in  this  case  in  the  tympanum." 

It  is  said  that  hearing  has  been  preserved  on  the  affected  side 

*  See  Numbers  for  November  and  December,  1845,  with  a  careful  resumS  of  the  opi- 
nions of  rhese  gentlemen  in  Ranking'^  Half-yearly  Abstract,  vuls.  il  and  iii.,  from  which 
latter  work  the  foregoing  extract  is  taken. 


in  some  of  these  accidents;  even  after  the  stapes  has  been  separated 
from  the  fenestra  ovalis,  and  the  fracture  had  passed  through  the 
walls  of  the  labyrinth;  but  I  think  this  assertion  requires  further 
proof.  Notwithstanding  the  invariably  fatal  character  of  the  fore- 
going symptom,  a  case  has  been  related  in  which  a  f>ortion  of  brain 
is  said  to  have  escaped  through  the  ear,  and  the  patient  recovered. 
In  severe  dysuria,  urine  has  been  discharged  from, the  ears.  He- 
morrhage may  occur  from  the  ear  as  the  result  of  ulceraUon;  and 
the  carotid  has  been  tied  to  arrest  profuse  bleeding  from  the  ear, 
for  which  see  the  section  on  Otitis  from  scarlatina,  page  340. 


The  inflammatory  affections  of  the  middle  ear  are  so  well  cha- 
racterized in  those  of  the  membrana  tympani,  with  which  they  are 
generally  associated, — their  symptoms  have  been  so  fully  entered 
into, — and  their  treatment  discussed  at  such  length  in  the  preced- 
ing portions  of  this  work,  that  it  is  only  necessary  briefly  to  enu- 
merate their  different  forms,  to  specify  their  peculiar  symptoms 
and  results,  and  to  describe  the  best  mode  of  treatment. 

Acute  otitis,  or  inflammation  of  the  lining  membrane  of  theca- 
vitas  tympani,  is  one  of  the  most  painful  affections  which  can  be 
suffered ;  and  it  is  also  at  times  one  of  the  most  fatal.  It  may  occur 
at  all  periods  of  life,  but  is  generally  a  disease  of  youth  and  mid- 
dle age.  It  is  usually  induced  by  cold,  or  any  of  those  exciting 
causes  detailed  under  the  head  of  severe  myringitis, — like  which 
disease,  a  sudden  accession  of  pain  in  the  middle  or  towards  the 
end  of  the  night  is  often  the  first  warning  which  the  patient  re- 
ceives. In  many  of  those  violent  fits  of  screeching  (occasionally 
attended  with  convulsions)  with  which  children  sometimes  awake 
out  of  sleep,  the  true  cause  is  otitis.  The  pain  is  described  as  of 
the  most  excruciating  character,  and  likened  "  to  that  of  a  sword 
piercing  through  the  ear  into  the  brain ;"  and,  although  this  ex- 
treme suffering  intermits,  it  is  only  to  be  replaced  by  a  dull,  ach- 
ing, and  incessant  throbbing  in  the  ear,  and  pain  and  soreness  often 
extending  over  the  whole  side  of  the  head  and  down  along  the 
neck.  The  feeling  usually  complained  of  in  these  quiescent  mo- 
ments is  that  of  a  "  bursting  in  the  ear.*'     There  is  occasionally 


at  the  very  commencement  over-acute  hearing  ;  but,  in  the  pro- 
gress of  the  disease,  when  mucus  has  accumulated  in  the  cavity 
of  the  tympanum,  audition  is  always  impaired,  and  in  a  short  time 
total  deafness  ensues.  Pressure  upon  the  palate  opposite  J  the 
guttural  end  of  the  Eustachian  tube,  or  coughing,  sneezing,  blow- 
ing the  nose,  mastication,  and  even  deglutition,  increases  the  pain. 
There  is  also  tinnitus  present,  which  is  generally  of  a  low,  hum- 
ming character,  but  is  sometimes  compared  to  a  '*  loud  hammer- 
ing." The  physical  signs  are,  a  brownish-red  colour  of  the  mem- 
brana  tympani,  which  is  sometimes  bulged  into  the  meatus ;  but  the 
vascularity  is  seldom  so  florid  br  well  marked  as  in  myringitis ;  if 
the  meatus  has  been  engaged,  the  external  surface  of  the  mem- 
brane is  often  whitish,  presents  a  macerated  look,  and  its  epithe- 
lium appears  to  be  peeling  off.  The  patient  cannot  inflate  the 
tympanum, —  either  owing  to  obstruction  from  inflammation  ex- 
tending through  the  Eustachian  tube,  or  from  the  cavitas  tympa- 
num being  filled  with  extraneous  matter ;  and  the  endeavour  to  do 
so  increases  the  pain  and  sensation  of  bursting  in  the  ear.  In  most 
cases  of  severe  otitis,  the  external  auditory  conduit  is  also  engaged, 
and  the  membrane  of  this  passage  is  swollen  and  thickened,  so  as 
to  intercept  our  view  of  the  membrana  tympani ;  and  the  auricle 
itself  frequently  participates  in  the  inflammatory  action,  and  be- 
comes swollen,  oedematous,  and  of  a  livid  colour.  The  mastoid 
process  in  the  later  stages  of  the  disease  (after  it  has  continued 
some  days)  is  generally  tender  to  the  touch,  and  its  integument 
red  and  swollen.  In  such  cases  it  should  be  carefully  examined 
daily,  according  to  the  method  recommended  at  page  56. 

Facial  paralysis,  from  extension  of  the  inflammation  to  the 
bony  canal  in  which  the  portio  dura  nerve  passes  round  the  tym- 
panum, sometimes  attends  otitis,  to  which  symptom,  as  a  special 
affection,  a  section  is  devoted  at  page  346.  The  mucous  mem- 
brane of  the  throat  is  often  of  a  dusky  red,  and  sometimes  the 
submucous  tissue  infiltrated  and  swollen ;  and,  should  the  attack 
have  originated  in  exposure  to  cold,  it  is  often  attended  with  in- 
creased mucous  discharge  from  the  nose,  a  stuffing  in  the  frontal 
sinus,  some  suffusion  of  the  conjunctiva,  and  also  slight  lachry- 


In  addition  to  these  local  symptoms,  the  patient  laboiin  under 
considerable  fever;  the  tongue  is  white,  dry,  and  often  furred: 
the  pulse  quick  and  hard ;  the  skin  dry,  the  bowels  constipated, 
the  urine  scanty  and  high-coloured ;  but  there  is  not  much  thirst 
There  is  extreme  restlessness,  and  the  countenance  is  always  anx- 
ious,  and  highly  indicative  of  the  agony  experienced.     Intole- 
rance of  light  is  a  frequent  attendant,  and  delirium  not  an  un- 
common occurrence ;  and  in  aggravated  cases,  when  the  disease 
spreads  to  the  internal  car  and  the  contents  of  the  craniuiny  there 
is  generally  a  low  moaning  present,  and  not  unfrequently  a  tossing 
of  the  head  from  side  to  side.     When  the  head  becomes  engaged, 
the  patient  is  oden  unwilling  to  answer  questions,  or  to  be  dis- 
turbed in  any  way ;  is  occasionally  unconscious  of  surrounding  ob- 
jects ;  and  does  not  at  times  even  recognise  his  friends.  I  have  some- 
times seen  partial  coma  present,  from  which,  however,  the  patient 
could  easily  be  roused ;  and  convulsions  occasionally  occur,  parti- 
cularly in  young  subjects.     In  this  stage  it  is  often  difficult  for  the 
practitioner  in  attendance  to  diagnose  with  accuracy  the  precise 
nature  of  the  affection,  or  to  say  how  much  of  it  is  purely  local, 
and  how  much  dependent  upon  cerebral  irritation,  or  extension 
of  the  inflammation  to  the  brain  or  its  membranes.     The  cases 
detailed  at  pp.  238  and  247  are  good  examples  of  this  form  of 
disease,  as  well  as  its  appropriate  treatment.    It  must  be  borne  in 
mind,  that  inflammations  in  the  immediate  neighbourhood  of  the 
brain  often  give  rise  to  symptoms  of  a  peculiar  character,  of  which 
abscess  in  the  orbit  is  an  instance  well  known  to  surgeons. 

The  immediate  terminations  of  the  disease  are  threefold:  first 
by  resolution,  in  which  the  pain  gradually  lessens,  the  swelling 
subsides,  and  the  hearing  is  in  time  restored,  although  the  tinni- 
tus, then  generally  of  a  buzzing  character,  usually  remains  for  a 
long  time  after.  In  this  case  the  inflammation  either  never  pro- 
ceeded to  suppuration,  or,  if  muco-purulent  matter  had  accumu- 
lated within  the  tympanic  cavity,  it  was  absorbed,  or  it  found  a 
gradual  exit  through  the  Eustachian  tube,  leaving  the  lining  of 
the  middle  ear  thickened,  and  its  functions  consequently  impaired. 
In  the  second  termination  of  the  disease,  the  pent  up  matter  hav- 
ing burst  through  the  membrana  tympani  is  discharged  externally. 


and  relief  is  almost  immediately  experienced :  thus  showing,  that 
the  pain  chiefly  depended  upon  the  unyielding  nature  of  the  struc- 
tures bounding  the  space  within  which  it  was  contained.     The 
rupture  generally  occurs  either  opposite  the  opening  of  the  Eus- 
tachian tube  in  the  anterior  vibrating  portion  of  the  membraney 
or  immediately  adjoining  its  posterior  attachment,  behind  and  be- 
low the  mastoid  cells,  as  I  have  already  explained  at  page  139. 
With  the  free  communication  which  the  largest  of  these  cells 
has  with  the  tympanic  cavity,  and  the  continuity  of  structure  of 
their  lining  membrane  with  that  originally  engaged  in  the  tym- 
panum, it  could  scarcely  be  expected  that  a  diffused  inflammation, 
possibly  of  an  erysipelatous  character,  extending  over  the  mucous 
surface  of  the  tympanum,  would  stop  short  at  the  mastoid  cells, 
even  if  we  did  not  possess  facts,  derived  from  morbid  anatomy,  to 
establish  the  contrary  opinion.  The  very  large  quantity  of  purulent 
matter  which  escapes  through  the  external  meatus  when  the  outer 
septum  gives  way,  or,  as  the  patient  generally  expresses  it,  '*  some- 
thing bursts  in  the  ear,"  and  which  amounts  to  two  or  three 
drachms  at  the  moment,  must  have  struck  every  one  conversant 
with  aural  affections.     Where  does  this  come  from,  as  it  is  much 
more  than  the  tympanic  cavity  could  have  contained  ?     I  believe 
from  the  extensive  surface  of  the  mastoid  cells.     In  this  state  the 
case  becomes  one  of  internal  otorrhosa,  the  most  frequent  termi- 
nation of  acute  otitis. 

The  third  termination  is  always  dangerous,  and  often  fatal, 
and  should  make  the  surgeon  be  cautious  and  guarded  in  his  prog- 
nosis. The  inflammatory  process,  spreading  from  the  tympanal  ca- 
vity through  the  mastoid  cells  internally,  or  by  the  bony  meatus  to 
the  periosteum  covering  the  mastoid  process  externally,  produces 
disease  in  that  bone,  to  which,  and  the  treatment  required,  I  have 
already  referred  at  pages  237  and  251.  In  such  a  condition  the 
case  is  one  of  danger,  but  not  to  such  an  extent  as  that  where  the 
inflammation  is  propagated  to  the  dura  mater  through  the  thin 
lamina  of  bone  which  separates  it  from  the  mastoid  cells,  or  spreads 
by  the  way  of  the  labyrinth  to  the  internal  meatus,  and  meningitis 
or  cerebritis  supervene.  The  lateral  sinus  may  be  the  flrst  part 
affected,  but,  generally  speaking,  the  anterior  or  posterior  surface 


of  the  cranial  aspect  of  the  petrous  portion  of  the  temporal  bone 
exhibit  the  principal  evidence  of  disease,  being  either  of  a  dark- 
red  colour,  or  a  greenish  hue,  or  sometimes  merely  a  slight  pur- 
ple tinge.    Unhealthy  pus  at  times  forms  between  the  dura  mater 
and  the  bone;  at  others  the  inflammation  extends  to  the  brain, 
and  abscess  forms  in  the  substance  of  that  viscus ;  while  in  some 
other  cases  the  inflammation  is  of  a  more  diffused  character,  and 
effusions  from  all  the  extensive  serous  surfaces  both  of  the  me- 
ninges  and  the  ventricles,  as  well  as  phlebitis  of  the  lateral  sinus, 
take  place.     The  records  of  surgical  and  pathological  science 
detail  numbers  of  such  cases,  which  are  not,  it  roust  be  remem- 
bered, the  result  of  otorrhoea,  but  of  acute  inflammation  of  the 
middle  ear,  extending  to  the  contents  of  the  cranium,  and  end- 
ing fatally  in  a  few  days,  or  often  less.     The  lower  orders  in 
this  country  are,  from  experience,  well  acquainted  with  the  &tal 
nature  of  this  malady.     When  compiling  the  Tables  of  deaths, 
under  the  Census  Commission  for  1841,  my  attention  was  attracted 
to  the  niimber  of  cases  in  which  '*  died  of  a  pain  in  the  ear,"  or 
"  was  suddenly  struck  with  a  pain  in  the  ear,**  was  returned  as  a 
cause  of  death ;  and  I  find  in  the  present  Census  inquiry  that  simi- 
lar information,  and  to  rather  a  greater  extent,  has  been  afforded. 
As  many  such  cases  have  resulted  from  persons  having  fallen 
asleep  in  the  open  air,  the  popular  belief  attributes  the  disease  to 
the  entrance  of  insects  or  noxious  animals  into  the  ear,  and  in  the 
case  of  young  children  who  awake  suddenly  screaming  in  a  most 
unearthly  tone,  and  who  are  often  seized  with  convulsions,  and 
generally  die  comatose,  the  vulgar  impression  is,  that  they  have 
been  "  taken  by  the  fairies."*     The  Irish  term  for  the  disease, 
Daigh  cluaise,  **  a  darting  pain  through  the  ear,*"  is  expressive  and 

By  comparing  the  foregoing  description  with  that  previously 
given  of  myringitis,  it  will  be  seen  that  the  two  affections  have, 
in  their  severest  form,  a  number  of  symptoms  in  common,  but 

*  Althoagh  these  popular  fanciea  and  folks'  lore  are  fast  passing  away,  it  is  stin  of 
some  importance  that  medical  men,  practising  in  the  country,  should  be  familiar  with  the 
opinions  of  the  i)easantr>'  upon  the  subject,  as  well  as  the  names  of  the  diseases  which  thej 
have  to  treat 


in  that  now  under  consideration,  they  are  generally  more  aggra- 
vated ;  there  is  a  greater  feeling  of  fulness  and  bursting ;  the  pain 
is  of  a  more  violent  character,  and  the  extent  both  of  it  and  of 
soreness  to  the  touch  over  the  mastoid  region  and  the  side  of  the 
head,  are,  if  closely  attended  to,  sufficient  to  mark  a  differential 
diagnosis.     The  more  freqiient  extension  of  the  inflammation  to 
the  external  auditory  canal  and  the  auricle,  as  well  as  the  peculiar 
appearance  of  the  membrana  tympani  itself,  will  still  further  assist 
in  the  formation  of  an  opinion.     But  when  the  inflammation  ex- 
tends to  the  parietes  or  contents  of  the  cranium,  it  is  of  great  mo- 
ment that  the  practitioner  should  be  aware  of  every  symptom 
superadded  to  those  peculiar  to  the  aural  disease  alone,  even  in 
the  early  stage  of  the  affection,  as,  when  coma,  convulsions,  or 
stertor  ensue,  the  head  symptoms  are  too  well  marked  to  render 
mistake  possible ;  but  the  mischief  has  generally  been  done  at  that 
period,  and  treatment  will  avail  little.     I  have  seen  delirium,  ap- 
parently more  the  result  of  suffering  than  any  interference  with 
the  sensorium,  so  frequently  attend  inflammation  of  the  membrana 
tympani,  and  even  the  meatus,  that  I  do  not  think  it  is  of  itself  a 
pathognomonic  of  suflBcient  importance  to  lead  to  the  belief  that  the 
brain  is  affected ;  but  incoherence,  or  much  hesitation  and  irregu- 
larity of  answering,  or  of  understanding  what  is  said,  is  generally 
characteristic  of  cerebral  disease.     So  is  intolerance  of  light  and 
contraction  of  the  pupils,  tossing  of  the  head  from  side  to  side,  and  a 
feeling  of  weight  as  well  as  pain  referred  to  the  whole  head.  Ver- 
tigo is  also  a  symptom  deserving  of  attention. 

In  addition  to  the  general  expressions  of  pain,  particularly 
during  a  paroxysm,  there  is  a  constant  low  moaning,  highly  cha- 
racteristic of  cerebral  affections.*  Rigors  occur  when  abscesses 
are  forming  within  the  cranium,  but  do  not  usually  attend  suppu- 
ration of  the  ear  itself,  or  of  the  eye  or  orbit.  Dr.  Graves,  in  the 
last  edition  of  his  Clinical  Medicine,  has  called  attention  to  the 
occurrence  of  rigors  during  fever,  when  detailing  the  case  of  a 
patient  who,  in  addition  to  the  usual  symptoms  of  headach,  hot 
skin,  thirst,  nausea,  acceleration  of  pulse,  and  gastro-intestinal 

*  Dr.  Graves  relates  a  case  of  ear-ache  in  fever,  in  which  the  symptom  of  moaning 
was  diagnostic  of  head  disease.     London  Medical  and  Surgical  Journal,  vol  iil,  p.  lOS. 


irritation,  had  a  daily  succession  of  slight  and  transient  rigors. 
His  words  are: — **  Now,  whenever  you  meet  with  a  symptom  of 
this  description  in  fever,  be  on  your  guard ;  watch  the  case  with 
anxious,  unremitting  attention,  and  never  omit  making  a  careful 
examination.  It  is  in  this  way  that  one  of  the  worst  complications 
of  fever — treacherous  and  fatal  disease  of  the  brain — very  often 
commences.  On  examining  this  girl,  we  found  that  she  had  not 
only  headach  but  also  ncute  pain  referred  to  the  left  ear,  the  ex- 
ternal meatus  of  which  was  observed  to  be  hot  and  tender  to  the 
touch.  In  addition  to  this,  we  were  informed  by  the  nurse  that 
she  had  been  seized  with  a  sudden  fit  of  vomiting  shortly  after 
wc  left  the  ward  on  the  day  before.  Here  was  an  array  of  threat- 
ening symptoms  calculated  to  awaken  attention  in  any,  even  the 
most  liecdless,  observer.  A  patient,  after  exposure  to  cold,  is 
attacked  with  symptoms  of  fever ;  she  has  headach  and  rest- 
lessness; she  then  begins  to  complain  of  acute  pain  in  the  ear, 
darting  inwardly  towards  the  brain ;  and,  finally,  is  seized  with 
sudden  vomiting.  Under  these  circumstances,  it  is  not  difficult 
to  form  a  diagnosis,  and  there  can  be  little  doubt  but  that  the 
phenomena  here  presented  were  indicative  of  incipient  inflamma- 
tion of  the  membranes  of  the  brain.  It  is  not  easy  to  say,  whe- 
ther in  such  cases  the  inflammatory  affection  of  the  membranes 
precedes  the  external  otitis,  or  whether  the  inflammation  com- 
mences in  the  external  ear  and  spread  inwards,  though  I  am  in- 
clined to  adopt  the  latter  supposition,  and  the  circumstance  of  the 
fever  and  car-ache  arising  from  cold  seems  to  give  an  additional 
degree  of  probability  to  this  view  of  the  question"  (vol.  i.  p.  191). 
Sickness  of  stomach,  is  not,  however,  a  symptom  I  have  often  re- 
marked in  auro-cerebral  inflammations. 

Thus  far  do  we  observe  the  symptoms,  and  note  the  immedi- 
ate terminations,  of  acute  otitis;  but  even  after  the  patient  may 
have  recovered  from  the  second  termination, — that  by  suppuration 
througli  the  membrana  tympani, — it  cannot  be  said  that  he  is  safe, 
for  chronic  disease  may  go  forward  in  the  part,  inflammation  or 
caries  of  the  bones  may  extend,  and  produce  disease  within  the  cra- 
nium at  a  more  or  less  distant  period. 

With  respect  to  treatment,  that  recommended  in  acute  myrin- 


litis,  carried  out  to  the  fullest  extent,  is  imperatively  demanded. 
Leeches  should  be  applied  plentifully ;  two  or  three  to  a  child,  four 
or  six  in  a  young  person ;  and  from  twelve  to  twenty  in  an  adult; 
round  the  meatus,  in  front  of  the  tragus,  and  behind  the  auricle 
over  the  mastoid  process ;  and  repeated  by  small  relays  from  time 
to  time,  even  in  the  course  of  the  four-and-twenty  hours.     Mer- 
cury is  even  more  necessary  here  than  in  cases  of  myringitis ;  it 
should  be  commenced  at  once,  and  with  a  twofold  object:  to  ar- 
rest the  disease  in  the  ear,  and  should  it  fail  in  so  doing,  to  check 
its  inward  progress  to  the  brain.     If  we  find  the  aural  disease 
succumb  to  the  depletion,  mercury,  and  other  means  employed, 
we  may  hold  back  the  mercury  by  lessening  its  quantity  or  in- 
creasing the  interval  between  its  doses,  but  not  omitting  its  use 
altogether  so  long  as  any  symptoms  remain  which  might  indicate 
extension  of  the  disease.     Blisters  behind  the  ears,  fomentations^ 
and  poultices,  &c.,  as  detailed  in  the  former  sections,  may  be  called 
into  requisition,  according  as  they  afford  relief  in  each  particular 
case.     So  soon  as  it  can  be  determined  that  matter  has  formed 
under  the  periosteum,  or  that  that  structure  itself,  or  the  bone  of  the 
mastoid  process  beneath  it,  is  deeply  implicated  in  the  inflamma- 
tion, the  surgeon  should  not  hesitate  to  make  a  free  incision,  as  I 
have  recommended  at  page  237.  Promptness  and  decision  in  this 
matter  will  oflen  save  a  patient's  life  even  in  an  advanced  stage  of 
the  disease.  It  has  been  suggested  to  open  the  membrana  tympani 
in  order  to  give  an  early  exit  to  the  imprisoned  fluid ;  and  when 
it  can  be  done  with  facility,  and  without  injuring  the  parts  beyond, 
I  see  no  objection  to  the  practice,  although  I  myself  have  no  ex- 
perience of  it.    A  difficulty,  however,  presents  in  the  usually 
thickened  and  inflamed  condition  of  the  external  meatus. 

The  case  referred  to  at  page  301  is  also  a  good  example  of 
auro-cerebral  inflammation. 


Notwithstanding  the  severity  of  the  symptoms  in  the  forego* 
ing  disease,  rupture  of  the  tympanal  cavity  from  inflammation  of 
its  mucous  lining  often  takes  place,  with  a  much  shorter  and  less 
painful  form  of  disease,  in  which  the  patient  says  he  was  relieved 



afler  a  few  hours'  Buffering  by  the  '*  abscess  in  the  ear  having 
opened  ;**  that  ever  since  he  has  been  very  deaf;  and  that  when- 
ever he  coughs  or  blows  his  nose,  the  air  and  discharge  goi]^ 
through  his  ear.     Upon  examination  we  generally  find  a  ruptme 
of  the  membrana  tympani  at  its  posterior  inai]gin,  the  meatus  is 
often  a  good  deal  thickened,  and  the  membrana  tympani  even 
more  engaged  in  the  inflammatory  affection  than  in  the  former 
case.     This  increased  morbid  action  in  the  membrana  tympani, 
together  with  some  ulceration  of  its  mucous  surface,  may  have  led 
to  the  early  rupture  and  evacuation  of  the  contents  of  ihe  tympa- 
nic cavity ;  the  mastoid  cells  are  seldom  engaged  in  this  form  of 
the  disease.     We  (ind  an  analogue  to  this  affection  in  inflammi- 
tion  of  the  eye.     In  some  cases  of  suppuration  of  the  globe,  or  of 
matter  contained  in  the  anterior  chamber,  the  cornea  remains  o- 
tirc  for  several  days,  while  in  other  cases  of  very  much  less  amoimt 
of  mischief,  the  cornea  opens  by  ulceration,  the  contents  of  tie 
chamber  are  evacuated,  the  pain  ceases  as  soon  as  the  tension  is 
removed,  and  the  eye  recovers  without  further  mischief,  or  but  t 
slight  adhesion  between  the  iris  and  the  corneal  cicatrix. 

The  occurrence  of  otarrhcea  during  the  progren  <^  pkAuitj 
must  have  attracted  the  attention  both  of  the  phymcian  and  the 
aural  practitioner.  In  such  cases  I  generally  find  the  membrani 
tympani  perforated,  and  a  thin  purulent  discharge  pouring  out  of 
the  meatus,  and  also  pumped  through  the  aperture  in  the  mem- 
brana tympani  in  considerable  quantity.  Upon  inquiring  into  the 
history  of  the  case,  it  will  generally  be  found,  that  comparatively 
little  pain  was  experienced,  commensurate  with  the  amount  of 
injury  done  to  the  parts ;  deafness  and  discharge  being  often  the 
first  symptom  which  attracted  the  patient^s  attention.  It  is  pro- 
bable that  in  all  these  cases  subacute  ulcerative  inJlammatuM  ex- 
tended into  the  tympanal  cavity  through  the  Eustachian  tube, 
and  so  thinned  the  membrana  tympani  that  it  gave  way  in  a  fit  of 
coughing,  without  the  patient  being  at  all  conscious  of  the  occu^ 
rcnce  at  the  moment.  No  hope  of  amendment  can  be  held  out  in 
such  cases,  nor  indeed  should  treatment  be  attempted,  except  that 
of  keeping  the  parts  cleansed,  and  using  some  very  mild  astringent 
lotion,  or  a  weak  solution  of  chloride  of  lime,  which  serves  to 


correct  the  foetor  sometimes,  but  not  always,  attending  this  form 
of  otorrhoea. 

In  otitis,  or  inflammation  of  the  tympanal  cavity  in  any  of  its 
forms,  whether  violent  or  mild,  lymph  must  be  effused  upon  the 
surface  of  the  membrane,  as  well  as  pus  poured  into  the  cavity,  in 
the  same  way  as  we  find  lymph,  pus,  and  serum  in  the  bag  of  the 
pleura  or  the  peritoneum ;  for  I  am  inclined  to  think,  that  as  soon 
as  inflammation  attacks  the  tympanic  cavity,  the  Eustachian  out- 
let is  so  much  closed,  that  it  becomes  a  shut  sac,  liable  to  all  the 
phenomena  attending  inflammation  in  serous  cavities.  Hence 
those  bands  of  adhesion  passing  between  the  sides  of  the  cavity, 
as  well  as  its  contents,  so  oden  observed  after  death,  and  to  which 
I  have  so  frequently  referred  in  the  foregoing  chapter,  and  which 
must  produce  collapse  of  the  membrana  tympani  and  impairment 
of  hearing. 

ExarUhematauB  otitis,  to  which  I  have  already  referred  at  page 
277,  is  manifestly  an  acute  inflammation  of  the  mucous  lining  of  the 
tympanal  cavity, — an  extension  of  the  same  unhealthy  affection 
so  frequently  seen  in  the  throat  of  persons  labouring  under  scar- 
latina and  measles,  &c.,  spreading  upwards  through  the  Eustachian 
tube,  and  which  not  only  attacks  the  internal  surface,  but  shows 
itself  in  the  form  of  glandular  swellings,  diffuse  inflammation,  and 
purulent  deposits  in  the  neck.  I  must  again  repeat  what  I  have 
already  mentioned,  that  practitioners  do  not  sufficiently  attend  to 
the  state  of  the  ear  in  scarlatina,  and  that  they  neglect  the  appli- 
cation of  remedies  for  a  disease  which  is,  even  in  the  unhealthy 
condition  which  the  patient  usually  is  at  the  moment,  amenable  to 
treatment,  and  the  omission  of  which  has,  in  numbers  of  instances, 
led  to  permanent  deafness,  and  when  the  patient  is  young,  to  con- 
sequent muteism.  That  I  am  not  overstating  the  case  may  be 
learned  by  any  person  who  will  examine  the  records  of  deaf  and 
dumb  institutions,  or  inquire  into  the  causes  of  acquired  muteism. 
Thus,  irom  the  latest  authentic  Continental  Table — that  published 
by  the  Belgian  Government  in  1847,*  we  learn  that  of  1892  cases 
of  acquired  muteism  from  all  causes,  216  were  from  scarlatina,  80 

*  See  Dr.  Sauvenr's  investigatioiui  in  the  Chapter  on  Deaf-Dambnesa,  at  the  concloaion 
of  this  work. 



from  measles,  and  28  from  small-pox ;  from  the  Americmn  TaUei^ 
— out  of  86  cases  of  non-congenital  muteism,  as  many  ma  41  were 
from  scarlatina  ;* — and,  according  to  the  investigations  in  which 
I  have  been  engaged  under  the  present  Censos  Gonuniflsion  in 
Ireland,  I  find  that  of  394  cases  of  specified  causes  of  aoquiied 
muteism,  in  35  instances  it  arose  from  scarlatina;  in  12  firom  smalt 
pox ;  and  in  7  from  measles ;  in  all  54  ;t  from  exanthematooi 
otitis,  or  1  in  7*30  of  the  whole;  and  I  am  inclined  to  think,  that 
this  proportion  is  even  less  than  what  actually  exists,  for  many 
cases  were  returned  as  '*  Diseases  of  the  Ear,"  or  a  *'  Dischiige 
from  the  Ear,**  acquired,  no  doubt,  during  some  of  those  fekile 
diseases  just  specified.  The  most  immanageable cases  of  otorrboea 
which  I  have  met  with  in  practice,  those  in  which  most  destmo- 
tion  has  taken  place,  and  where  the  ossicula  have  been  most  fins- 
qucntly  lost,  have  been  the  result  of  scarlatina  or  measles. 

Life  may  be  lost  from  exanthematous  otitis,  even  as  a  secon- 
dary affection,  of  which  a  remarkable  example  is  afforded  by  Fh>- 
fessor  Porter,  in  the  first  volume  of  Dr.  Graves*s  Clinical  M^iciiw^ 
in  which  a  boy  had  an  attack  of  otitis  while  sufifering  from  scarla- 
tina ;  he  recovered  the  latter  affection,  but  had  facial  panlysiib 
with  profuse  otorrho&a,  and  was  weak  and  emaciated.  At  the 
end  of  six  weeks  profuse  hemorrhage  burst  from  the  external 
meatus ;  '*  the  child  had  been  asleep,  when  he  suddenly  awoke, 
screamed  out '  Oh !  my  car,  my  ear  V  when  almost  instantly  a  gosh 
of  blood  took  place  from  the  right  ear.  This  blood  was  florid, 
and  had  the  appearance  of  being  arteriaL""  Professor  Porter,  who 
was  present  during  one  of  the  attacks  of  hemorrhage,  writes :  '*  He 
seemed  to  have  no  previous  warning  whatever:  sometimes  the 
bleeding  commenced  during  sleep,  sometimes  while  he  was  amus- 
ing himself  with  his  toys.  He  generally  gave  a  single  scream  at 
the  instant,  and  then  the  blood  burst  forth  with  a  gush  thatzeally 
astonished  me.  I  never  saw  blood  lost  so  rapidly  in  any  surgical 
operation  I  ever  witnessed,  and  only  once  in  an  accident,  where  the 
deep  jugidar  vein  had  been  opened.     This  bleeding  could  hardly 

*  American  AnnaLi  of  the  Deaf  aiid  Damb,  voL  L  No.  1,  p.  81. 
t  See  Report  of  the  Irish  Census  Commissioners  upon  The  SUtus  of  DiaesM^  mn  >0* 
and  also  Chapter  IX.  of  this  woric,  on  Deaf-Domkmess. 


be  controlled  by  pressure,  and  the  attempt  to  do  so  caused  intense 
pain,  so  that  at  times  the  nurse  did  not  interfere,  but  allowed  it 
to  stop  spontaneously,  which  it  generally  did  in  about  a  minute. 
About  a  week  before  his  death,  I  observed  that  the  blood  was  be- 
ginning to  make  its  way  by  the  Eustachian  tube  into  the  pharynx, 
some  of  which  passed  into  the  stomach,  and  some  was  expelled 
by  the  mouth,  and  then  he  bled  sometimes  by  one  passage,  some- 
times by  the  other,  and  occasionally  by  both.  I  need  not  say  that 
he  became  pale,  ex-sanguine,  and  exhausted,  except  to  express 
surprise  that  any  child  of  his  age  could  have  endured  so  long. 
The  palate  and  inside  of  his  mouth  was  as  pale  as  any  part  of  the 
external  surface  of  his  body.  Exactly  at  the  end  of  the  thirteenth 
week  from  the  commencement  of  his  illness,  he  died  after  a  slight 
gush  of  blood."  There  was  no  post-mortem  examination,  but  the 
author  believed,  and  with  every  reasonable  probability,  that  the 
carotid  artery  had,  by  ulceration,  opened  into  the  Eustachian 
tube,  where  those  two  canals  are  only  separated  by  a  very  thin 
septum  of  bone. 

A  case  is  related  in  the  Edinburgh  Monthly  Journal,  No.  ni., 
of  a  child  eleven  years  of  age,  who  had  a  severe  attack  of  scarla* 
tina,  with  suppurative  otitis  in  both  ears,  from  whose  right  ear  a 
sudden  discharge  of  blood  occurred  on  the  fifteenth  day.  The 
hemorrhage  returned  three  times  in  great  quantity  during  the 
six  following  days.  Mr.  Syme  tied  the  carotid  artery,  which 
checked  the  bleeding,  but  the  case  terminated  fatally  on  the  ele- 
venth day  after  the  operation,  apparently  from  cerebral  disease. 
Upon  examination  it  was  discovered  that  the  carotid  was  not  con- 
cerned in  the  disease,  but  that  the  blood  came  irom  the  lateral 
sinus,  the  bony  septum  between  which  and  the  cavity  of  the  ear 
had  ulcerated  through  at  one  point. 

Of  the  deafness  from  fever  I  have  ahready  spoken  at  page  277, 
when  describing  the  condition  presented  by  the  merabrana  tym* 
pani  as  the  result  of  that  affection ;  and  the  remarks  there  made  are 
equally  applicable  here.  That  the  effects  of  this  disease  are  much 
more  common  than  is  generally  supposed,  may  be  learned  from  the 
Irish  Census  Returns  already  alluded  to  at  page  340 ;  for,  of  the  394 
cases  of  acquired  muteism  from  specified  causes,  in  61  persons, 


31  males,  and  30  fomaleSy  the  difleaae  was  atiribaied  to  fever. 
Besides  which,  a  number  of  cases  of  partial  deafness^  the  result 
of  fever,  present  daily  at  our  public  institutions*  In  a  countij 
where  fever  prevails  so  extensively,  it  is  a  matter  of  mirpme  that 
so  few  cases  of  muteism  have  resulted ;  and  the  circumatanoe  can 
only  be  attributed  to  the  fact  of  those  attacked  having  been  at 
the  time  of  adult  age,  and  who,  consequently,  never  <x>inplctely 
lost  the  power  of  speech,  although  many  are  partially  dea£ 

Another  result  of  typhus  fever  is  dumbneM^  one  of  the  most 
notable  cases  of  which  has  been  related  by  Dr.  Foley,  of  KilmslL 
The  following  are  the  particulars: — A  boy,  aged  13,  had  a  bad 
attack  of  typhus  in  1839,  and  afVer  a  severe  struggle  reeoveied, 
but  with  paralysis  of  the  right  side  and  total  loss  of  the  power  of 
speech ;  it  was,  however,  believed  that  he  was  not  dea(  aa  he  could 
still  hum  tunes.  He  soon  recovered  from  the  paralysis,  bat  remained 
dumb  for  eight  years,  when  my  attention  was  directed  to  the  p^ 
culiarities  of  his  case  while  engaged  in  making  inquiriea  into  tlis 
circumstances  of  the  deaf  and  dumbunder  the  present  Cenaus  Gooh 
mission.  I  communicated  with  Dr.  Foley,  who  kindly  afforded  me 
many  interesting  particulars  of  the  case,  and  also  published  the  fol- 
lowing additional  account  of  it  in  one  of  the  periodicala  :•—**  During 
recent  inquiries  made  about  the  case,  I  find  that  the  patient  eoa- 
tinned  completely  dumb  for  the  space  of  eight  years,  after  which 
he  and  every  member  of  his  family  were  seized  with  typhus  fevtt 
Towards  the  termination  of  the  disease  he  was  obaervod  to  arti* 
culate  one  or  two  short  words  at  different  times.  As  convales- 
cence progressed,  pains  were  taken  to  teach  him  a  few  more,  and 
by  very  slow  degrees,  indeed,  he  was  gradually  brought  on,  so 
that  now,  at  the  end  of  three  years,  he  can  speak  very  dietinetly, 
but  at  times  so  rapidly  as  to  cause  him  great  embarrassment.  Tbs 
intensity  of  the  disease  must  have  been  much  less  in  the  last  at- 
tack than  the  former,  as  in  the  first  he  was  quite  unconscioiM 
nearly  from  the  commencement ;  while  in  the  latter,  he  has  stated 
to  me,  that  he  never  lost  his  recollection.  He  has  a  perfect  me- 
mory of  every  circumstance  since  his  fever  in  1839  ;  was  well 
aware  of  the  privation  under  which  he  laboured,  and  theref(»e 
shunned  intercourse  with  all  except  members  of  his  own  family. 


P0BT<*7BBRILS  DUMBN888.  843 

He  understood  very  well  the  jeers  and  observations  made  by  those 
thoughtless  young  persons  among  whom  he  was  often  obliged  to 
be ;  galling  as  they  were  to  his  feelings,  he  had  no  way  to  defend 
himself,  and  could  not  convey  that  he  comprehended  every  word 
as  well  as  any  of  them.  I  questioned  him  on  different  occurrences 
that  took  place  since  he  had  been  my  patient  in  1839,  and  found 
that  hb  memory  on  and  acquaintance  with  them  was  quite  ac- 
curate ;  so  that  I  have  no  doubt  of  the  correctness  of  his  compre- 
hension during  the  eight  years  of  his  dumbness.  He  told  me  that, 
since  the  original  disease,  he  felt  a  '  weakness^  in  the  right  side  of 
his  body  that  never  prevented  his  power  of  moving,  but  yet  made 
him  feel  *  uncomfortable;'  that,  as  the  power  of  speech  returned, 
the  '  weakness*  was  diminishing,  so  that  now  he  scarcely  feels  it 
I  stated  in  the  original  Report  that  he  exhibited,  during  the  fever^ 
a  very  severe  and  weU-marked  paralysis  of  the  right  side,  includ- 
ing  every  part  from  the  eye  to  the  toes ;  that  on  the  nineteenth 
day  it  had  nearly  disappeared,  and  he  was  soon  after  able  '  to  run 
about.'  There  seems  to  be  no  doubt  that  the  leading  feature  was 
meningeal  engorgement,  in  the  head  at  all  events,  and  probably 
continued  into  the  spinal  canal.  I  think  it  probable  that  strisB  of 
that  congestion  remained  at  the  base  of  the  skull,  compressing 
some  of  the  filaments  composing  the  roots  of  the  glosso-pharyngeal 
portion  of  the  eighth  nerve ;  as  also  of  the  ninth  on  the  same 

In  the  same  paper  Dr.  Foley  has  related  a  case  of  post-febrile 
dea&ess,  in  a  boy  about  eight  years  old,  and,  as  the  defect  of 
hearing  is  complete,  he  is  gradually  losing  speech,  and  can  now 
only  pronounce  a  few  words.  I  do  not  know  the  state  of  the  ear 
in  either  case.  I  possess  the  histories  of  three  cases  in  which  fe^ 
males  became  dumb  during  parturition :  they  were  also  partially 

Sir  Charles  Bell  has  related  a  most  interesting  case  of  disease 
of  the  ear  and  loss  of  speech,  which  bears  some  affinity  to  that 
recorded  by  Dr.  Foley,  and  of  which  the  following  is  an  abstract, 
nearly  in  the  words  of  the  narrator.     A  boy,  aged  10,  was  seized 

*  See  Medical  Times  and  Gazette,  for  May  8,  1852.    The  original  case  appeared  in 
the  Dublin  Medical  Press  of  September  9,  1840. 


with  obednate  pain  in  his  left  ear,  which,  extending  to  lua  head, 
&cef  and  teeth,  gave  him  no  rest  daj  or  night;  he  also  then  lost  the 
sight  of  his  right  eye.  He  recovered  from  this  attack  apparendj 
by  a  considerable  discharge  of  pus  from  the  ear,  attended  with 
intense  pain,  delirium,  and  convulsions.  Sometime  afterwaidi 
he  had  a  second  similar  attack,  remaining  insensible  for  half  sn 
hour,  and  when  he  awoke  to  consciousness,  *'  he  was  speechless.* 
When  brought  under  the  care  of  Sir  Charles  Bell,  he  had  a  dis- 
charge from  his  ear,  and  was  quite  deaf,  and  the  lefb  arm  was  pan^ 
lyzed ;  he  could  masticate  and  swallow  with  ease,  and  also  protnide 
the  tongue  and  turn  it  from  side  to  side ;  but  he  was  utterlj  unaUs 
to  pronounce  words.  The  consent  of  action  between  the  ehest» 
larynx,  and  mouth,  seemed  to  be  lost  shortly  after  the  foregoiiig 
note  of  his  case.  It  was  then  reported  that  he  was  able  to  whistle, 
but,  says  the  author,  **  on  witnessing  this  attempt,  we  find  thit 
he  makes  a  faint  noise  by  drawing  in  his  breath ;  and  that,  in  ftoC, 
he  cannot  whistle.**  In  this  state  he  remained  for  six  weeb 
longer,  when  we  read  that,  '*  his  efforts  confirm  the  former  stats- 
ment,  that  he  is  incapable  of  putting  the  tongue  and  larynx  into 
co-operation  in  speech.  The  mouth  is  shut,  the  tongoe  and 
larynx  perfectly  still,  and  he  makes  a  noise  by  impelling  the  air 
against  the  posterior  nares.**  Nine  months  after  the  time  when 
he  lost  his  speech,  ho  recovered  it  in  the  following  manner,  as 
related  by  his  mother: — ^'  Three  mornings  ago  he  recoTered  Us 
hearing  and  his  power  of  speech  at  the  same  time.  She  had  jost 
been  observing  that  he  could  not  be  very  ill,  since  he  was  tumUing 
about,  and  throwing  his  heels  over  his  head  in  bed.  Soon  after, 
his  sister  came  running  down  stairs,  saying,  that  her  brother  could 
speak,  and  a  quantity  of  matter  had  come  from  his  head  into  his 
mouth.  From  that  moment  he  could  hear,  and  vrith  a  painful 
degree  of  acuteness,  the  boy  saying  that  the  air  rushed  through  his 
head.  She  describes  his  voice,  too,  as  at  first  unnatural,  and  as  if 
he  spoke  with  difficulty ;  a  circumstance  which  cannot  surprise 
us,  when  we  recollect  that  it  is  nine  months  since  he  could  speak 
a  word.**  Bell  has  appended  the  following  remarks  to  this  cm> 
ous  case.  "  There  appears  to  have  been  an  abscess,  originally 
produced  by  disease  of  the  temporal  bone,  and  aflPecting  the 


nerves  of  the  base  of  the  brain,  first  afiecting  the  fifth  nerve,  and 
then  spreading  its  influence  to  the  seventh  and  ninth.  If  the  dis- 
ease had  produced  its  influence  mechanically,  and  by  pressurci 
there  would  have  been  no  obscurity,  and  one  side  only  would 
have  been  affected ;  but  I  imagine  that  the  inflammation  had  dis- 
turbed the  operations  of  the  nerves,  without  altogether  destroying 
their  influence,  deranging,  for  instance,  the  fine  associations  ne- 
cessary to  speech,  without  arresting  the  action  of  the  muscles  of 
the  tongue.  It  is  remarkable,  that  the  bursting  out  of  matter, 
probably  from  the  Eustachian  tube,  had  such  an  instantaneous  and 
simultaneous  effect  in  restoring  both  hearing  and  speech.*** 

Cases  of  congenital  dumbness,  without  deafness,  although  rare, 
have  now  been  fully  authenticated ;  and  a  very  remarkable  instance 
of  the  sudden  acquisition  of  speech  is  the  celebrated  case  related  by 
DeFoe,  of"  The  Dumb  Philosopher,  or.  Great  Britain*s  Wonder; 
containing :  A  faithful  and  very  surprising  account  how  Dickory 
Cronke,  a  tinner*s  son,  in  the  county  of  Cornwall,  was  born  dumb, 
and  continued  so  for  fifty-eight  years ;  and  how,  some  days  before 
he  died,  he  came  to  his  speech ;  with  memoirs  of  his  life  and  the 
manner  of  his  death." 

The  other  circumstances  relating  to  congenital  muteism,  will 
be  found  in  the  chapter  upon  Deaf-dumbness  at  the  conclusion  of 
this  work.  To  my  learned  friend.  Dr.  Travers,  I  am  indebted  for 
the  following  reference  to  one  of  the  ancient  authorities  upon 
deafness  occurring  during  fever: — 

*'  In  reply  to  your  note,  inquiring  about  deafness  as  a  symptom 
in  typhus  fever,  I  might  give  you  references  to  a  long  series  of 
authors  from  the  earliest  times,  but  the  indistinctness  of  the  cha- 
racters given  by  many,  indeed  a  majority,  of  the  earlier  writers, 
renders  it  often  difficult  to  determine  whether  the  disease  they 
described  is  identical  with  the  typhus  of  this  country.  It  will, 
probably,  be  sufficient,  irutar  omnium^  to  cite  Hippocrates,  who 
makes  frequent  mention  of  this  symptom ;  but  he  mentions  it  as 

•  The  Nervoos  System  of  the  Human  Body.  By  Charles  Bell,  F.  R  S.  London  t 
1830,  p.  cxviii.  See  also  Dr  Abercrombie*8  cases  in  the  Edinburgh  Medical  and  Surgical 
Journal  for  July,  1818. 


occurring  in  both  favourable  and  fatal  oaaea:  thus,  in  the  third 
book  of  his  Epidemics,  he  states  it  to  have  been  persistent  in  the 
case  of  HermocrateSy  who  died  on  the  twenty-seventh  day  of  die 
fever  ;Hipp.  Epidem.,  lib.  in.  §  1) ;  while  in  the  fiist  book  he 
had  described  it  as  occurring  on  the  nineteenth  night,  in  the  case 
of  Epicratis,  who  recovered  (lb.  lib.  i.  §  3).  He  mentions  it  also 
in  his  Aphorisms,  §  iv.  28,  49,  and  60  (with  which  compeie  Cet 
sus,  lib.  II.  capp.  6  and  8) ;  also  in  his  Coace  Pnenotione%  and  in 
several  places  of  his  Prorrhetica,  e.  g.,  1.  4, — kcu^woic  cy  6Stm.  al 
rapaxwStai  ira/KiJcoAou0ovoti,  kokov  See  also,  in  same  book,  {  li 
and  §  18.  In  the  seventeenth  century,  and  after  wards,  yoahavs 
EttmuUer,  Van  Swieten,  and  a  host  of  others.** 


Loss  of  motion  of  those  parts  of  the  face  supplied  by  the  por- 
tio  dura  of  the  seventh  pair  of  nerves,  and  generally  known  ss 
"Bell's  Paralysis/'  is  so  frequent  an  affection,  and  its  symptoms  so 
well  known,  that  it  is  unnecessary  here  to  enter  into  a  minute  de- 
scription of  its  character  and  appearance.  Pressure  on  the  nerve 
in  any  portion  of  its  course,  disease  of  the  brain,  caries  of  the  tem- 
poral bone,  or  other  organic  lesions  of  a  similar  character,  to  be 
described  under  the  head  of  Otorrhoea,  are  the  causes  most  um^ 
ally  assigned  for  this  affection.  Occasionally,  however,  the  phy- 
sician or  surgeon  meets  with  cases  of  facial  paralysis  which  had 
appeared  suddenly  and  without  any  ostensible  cause.  Such  cases 
are  usually  set  down  as  the  results  of  cold,  and,  generally  speak- 
ing, the  patient  states  that  he  had  been  exposed  to  a  draft  of  cold 
air,  opposite  a  broken  window,  an  open  door,  or  upon  the  top 
of  a  coach,  &c.,  immediately  before  the  disease  appeared.  It  still 
remains  to  be  proved,  that  the  application  of  cold  to  the  extrenii« 
ties  of  the  nerve  produces  paralysis  of  the  muscles  to  whick  it  is 
distributed ; — yet  such  has  been  the  only  mode  of  accounting  for 
some  of  the  cases  of  Bells  paralysis.  It  is  true,  that  if  we  care- 
fully examine  the  records  of  such  cases,  we  shall  find  dulness 
of  hearing,  tinnitus  aurium,  and  a  slight  pain  in  the  ear,  enume- 
rated among  the  symptoms;  but  until  I  called  attention  to  the 
subject  some  years  ago,  it  was  not  believed  that  the  paralysis  was 


produced  by  inflammation  of  the  ear  extending  into  the  aqueduct 
of  Fallopius.  In  my  Essay  upon  the  affections  of  the  membrana 
tympani,  I  stated  that  I  was  ^*  strongly  inclined  to  think,  that 
many  of  the  cases  of  paralysis  of  the  seventh  pair  of  nerves,  where 
we  have  no  mechanical  lesion,  such  as  caries  or  exfoliation,  and 
which  heretofore  were  usually  attributed  to  cold,  &c.,  may  have 
been  caused  by  some  form  of  otitis;  and  I  would,  therefore,  beg 
to  direct  the  special  attention  of  physicians  to  the  peculiar  condi* 
tion  of  the  ear  in  all  such  instances ;"  and  I  then  furnished  some 
cases  in  proof  of  my  opinion*  Since  that  time  I  have  had  exten- 
sive opportunities  for  testing  my  belief;  and  I  have  not  met  with 
a  single  instance  of  BelPs  paralysis  unaccompanied  by  otorrhoea, 
caries,  or  cerebral  affection,  in  which  there  was  not  manifest 
traces  of  disease,  or  its  results,  in  the  membrana  tympani,  or  in  the 
middle  ear.  Why  the  nerve  should  be  affected  in  cases  of  very 
slight  inflammation  of  the  cavitas  tympani  and  its  external  mem- 
brane,  and  not  in  those  in  which  there  is  violent  otitis  extending 
to  the  periosteum  and  the  mastoid  cells,  it  is  difficult  to  determine ; 
neither  can  I  offer  any  plausible  reason  for  loud  sudden  noises 
producing  such,  as,  for  instance,  in  the  case  of  Dr.  Bloxham,  of 
Portsmouth,  related  at  page  222.  The  traget  of  the  nerve  around 
the  tympanum  is  long  and  tortuous,  and  one  only  wonders  why 
it  is  not  more  frequently  affected.  The  following  case  affords  a 
good  example  of  this  disease. 

P.  R.,  aged  35,  suffered  from  typhus  fever  about  fourteen  years 
ago,  during  which  he  had  violent  pain  in  his  left  ear,  accom- 
panied by  a  discharge  which  has  continued  ever  since.  He  is 
quite  deaf  upon  this  side,  and  upon  examination  the  membrana 
tympani  is  found  to  be  perforated  at  its  anterior  portion,  and 
the  whole  membrane,  auditory  passage,  and  middle  ear  as  far  as 
can  be  seen  through  the  aperture,  are  of  a  bright  florid  red ;  the 
ossicula,  however,  remain  in  siiu. 

The  hearing  in  his  right  ear  remained  perfect  until  the  begin- 
ning of  May,  1847,  when  he  began  to  perceive  a  dea&ess  upon 
that  side,  which  after  a  few  days  was  accompanied  by  a  most  dis* 
tressing  noise  resembling  the  *'  escape  of  steam ;''  he  had  also  a 
rolling  noise  in  his  head,  but  no  pain  in  either  head  or  ear. ,    He 


sought  medical  advice,  and  had  **  drops"  of  an  irritatiiig  natore 
poured  into  the  meatus.  Not  having  derived  benefit  from  these, 
he  applied  at  St.  Mark^s  Hospital  on  the  29th  of  the  montL 
The  noise  and  deafness  were  as  already  described ;  in  addition,  he 
suffered  from  headach  and  pain  in  his  face.  The  right  mde  of  the 
face  was  then  completely  paralyzed,  presenting  the  usoal  appear- 
ance of  fulness  and  smoothness ;  the  mouth  drawn  to  the  left  side^ 
the  eye  staring  from  inability  to  close  the  lids,  the  tears  flowing 
over  upon  the  cheek,  the  nostril  collapsed,  the  colour  of  the  skin 
somewhat  heightened,  and  its  temperature  considerably  raised 
beyond  that  of  the  opposite  side.  The  auditory  canal  was  diy 
and  red ;  the  tympanal  membrane  had  completely  lost  its  polish, 
and  presented  an  uniform  pink  appearance,  not  unlike  blottbg- 
paper.  He  had  no  pain  anywhere  around  or  about  the  ear,  nof 
could  pain  or  soreness  be  produced  upon  making  pressure  in  any 
of  the  usual  situations.  He  was  able  to  inflate  the  tympanum; 
but  could  not  hear  the  watch  placed  to  the  ear  or  any  part  of  the 
head,  and  could  with  great  difficulty  distinguish  the  Toice. 

He  was  slightly  mercurialized  by  the  use  of  the  hydrargyrom 
cum  crct&,  with  cicuta ;  leeches  were  applied  several  times  round 
the  meatus,  and  small  blisters  over  the  mastoid  process.     As  soon 
as  his  mouth  became  sore  (in  about  ten  days),  the  hearing  re- 
turned, so  that  he  could  hear  ordinary  conversation  very  well; 
the  vascularity  of  the  membrane  lessened  considerably,  and  the 
noise  decreased.   On  the  15th  of  June  the  paralysis  had  quite  dis- 
appeared ;  he  was  then  obliged  to  discontinue  his  attendance  at 
the  hospital,  but  was  given  some  of  the  iodine  and  hydriodate  of 
potash  solution  to  take  occasionally.   Wishing  to  leam  the  result 
of  this  case,  I  sent  for  the  patient,  and  again  examined  him  upon 
the  10th  of  September  following.     He  had  no  return  of  the  par^ 
lysis ;  the  hearing  remained  much  the  same ;  the  meatus  was  still 
red;  the  merabrana  tympani,  over  the  head  and  handle  of  the  mal- 
leus, was  bright  red ;  the  rest  of  the  membrane,  with  the  exception 
of  one  clear  spot  in  front  of  the  point  of  the  maUeus,  presented  a 
dull,  pearly  hue ;  there  was  no  collapse  observable  in  it,  but  a  very 
opaque  rim,  like  a  broad  areas  senilis,  surrounded  its  lower  attach- 


If  we  take  up  Sir  Charles  Bellas  great  work  on  the  Nervous  Sys- 
tem, already  quoted  from,  we  shall  find  several  of  the  cases  therein 
so  graphically  detailed  confirming  the  foregoing  views.  Professor 
Roux,  of  Paris,  in  writing  the  history  of  his  own  attack  of  facial 
paralysis,  says : ''  During  the  course  of  this  complaint,  I  have  expe- 
rienced two  circumstances  which  may  lead  to  the  detection  of  the 
facial  nerve  becoming  affected: — 1.  The  membrane  of  the  tympa- 
num was  painfully  sensible  even  to  slight  noises.  2.  The  sense  of 
taste  was  affected  in  the  right  side  of  the  tongue,  so  that  everything 
tasted  metallic.  This  last  symptom  has  ever  been  a  precursor  of 
the  complaint,  being  observed  twenty-four  hours  before  the  oc- 
curreDce  of  paralysis."  The  disease  was  attributed  to  rheuma- 
tism ;  but  it  is  manifest  that  the  inflammatory  action  commenced 
in  the  ear,  affecting  first  the  chorda  tympani,  and  then  the  por- 
tio  dura.  The  case  of  J.  Richardson,  No.  3,  recorded  at  page  68 
of  Bell's  book,  is  evidently  one  of  acute  otitis,  producing  facial 
paralysis ; — Case  No.  33  is  of  a  like  nature,  but  neither  in  it,  nor 
in  any  of  the  other  cases  of  facial  paralysis  detailed  in  that  work, 
was  any  examination  made  of  the  membrana  tympani  or  the  mid- 
dle ear. 

Independently  of  the  cases  of  well-marked  facial  paralysis, 
such  as  those  detailed  in  the  foregoing  section,  I  have  frequently 
observed  a  trivial  affection  of  the  nerve  in  connexion  with  aural 
disease,  which  had  evidently  commenced  by  inflammatory  action 
in  the  tympanum,  or  its  external  membrane.  In  such  cases,  if  we 
stand  directly  opposite  the  patient,  while  the  face  is  in  a  state  of 
rest,  there  is  no  twisting  of  the  mouth,  nor  any  paralytic  condi- 
tion of  the  eyelids,  but  the  cheek  looks  slightly  fuller  than  that 
upon  the  opposite  side ;  and  the  ordinary  wrinkle,  or  curved  in- 
dentation, extending  from  the  comer  of  the  nose  to  a  point  a 
little  external  to  the  commissure  of  the  lips,  is  either  altogether  de- 
ficient, or  not  so  well  marked  as  that  upon  the  opposite  side ;  and 
if  we  engage  the  patient  in  conversation  so  as  to  bring  the  muscles 
of  expression  into  view,  all  the  foregoing  appearances  become 
exaggerated.  I  have  seen  many  such  cases,  where  this  symp- 
tom had  not  been  observed  by  the  patient  or  his  friends,  or  his 
medical  attendant. 


or  the  rheumatic  and  gouty  otitis  I  have  already  written,  and 
afforded  a  good  example  of  the  former  at  page  247,  in  the  case  of 
Mr.  F.,  and  this  is  a  form  of  the  disease  not  anosuallj  attended 
with  affections  of  the  facial  nerve. 


Catarrhal  inflammation^  extending  through  the  Enstachian 
tube  into  the  middle  ear,  and  producing  muculent  acoumnlatioii 
within  that  cavitj,  is  a  frequent  disease,  particularly  of  yonth  and 
early  life.  As  it  is  generally,  although  not  always,  attended  widi 
symptoms  of  subacute  inflammation  in  the  membrana  tympani, 
the  characters  of  both  diseases  have  so  much  in  common,  that  I 
must  refer  the  reader  to  the  descriptions  of  subacute  myringitis 
at  page  253,  and  of  strumous  myringitis  at  page  268.  A  number 
of  authors  have  written  upon  this  affection  under  different  ap* 
pellations,  such  as, — chronic  internal  catarrh;  catarrhal  otitis; 
and,  mucous  accumulation  in  the  cavity  of  the  tympanum ;  Mr. 
Pilcher,  as  '*  the  milder  form  of  acute  otitis  interna  ;**  and  by 
Dr.  Kramer,  who  has  given  a  very  good  account  of  the  disease,  it 
is  described  under  the  head  of  **  inflammation  of  the  mucous  mem- 
brane of  the  middle  ear,  with  accumulation  of  mucns;*  but,  like 
most  writers  upon  the  subject,  he  has  prefaced  his  observatioiis  hj 
a  lengthened  dissertation  upon  Eustachian  cathetcrism,  and  the 
introduction  of  gaseous  and  fluid  injections,  and  catgut  bouses, 
into  the  cavity  of  the  tympanum. 

The  familiar  instance  of  "  a  cold  in  the  head,"  in  which  there 
is  coryza;  impairment  of  smell;  stuffing  of  the  nose  and  frontal 
sinuses ;  thickening  and  some  increased  redness  of  the  fancial  mu- 
cous membrane ;  a  singing  or  buzzing  in  the  ears ;  and  partial  deaf- 
ness, relieved  occasionally  upon  blowing  the  nose,  coughing,  or 
sneezing,  when  a  feeling  is  experienced  as  if  something  **  cracked 
or  gave  way"  within  the  drum, — affords  a  good  example  of  many 
of  the  phenomena  attending  one  form  of  this  disease.  When  it 
attacks  young  persons,  or  children  at  school,  it  is,  as  already  men- 
tioned at  page  268,  too  frequently  attributed  to  inattention,  and 
time  is  allowed  to  pass  by  that  might  be  advantageously  employed 
with  treatment;    or  the  patient's  friends   excuse  themselves  by 

OATA&aHiX  OTITIS.  351 

saying  they  thought  it  was  "  only  a  cold.*'*  In  most  instances, 
the  disease  spreads  through  the  Eustachian  tube,  the  membrane  of 
which  being  thus  closed,  the  free  ingress  of  air  to  the  tympanum 
is  interrupted.  There  is  generally  a  sensation  of  fulness  in  the 
ear,  and  the  hearing  distance  is  at  first  very  variable,  being  alwajrs 
increased  after  each  rush  of  air  into  the  tympanum ;  but  as  the  dis- 
ease progresses,  if  not  relieved  by  nature,  or  controlled  by  art,  a 
general  dulness,  often  mistaken  in  young  persons  for  stupidity, 
remains.  Upon  applying  the  stethoscope,  while  the  patient 
forces  a  stream  of  air  into  the  cavitas  tympani,  by  holding  the 
nose,  and  making  a  forced  expiration,  or  by  the  surgeon  intro- 
ducing a  catheter,  and  employing  the  air-press,  a  gurgling  or 
crackling  sound  is  distinctly  heard  in  that  cavity,  and  very  fre- 
quently it  can  be  discerned  within  the  mastoid  cells  also,  showing 
that  thin  mucus  has  accumulated  in  these  localities,  no  doubt 
poured  out  from  the  irritated  and  inflamed  lining  membrane. 
Pain  is  seldom  complained  of,  but  the  mucous  membrane  of  the 
throat  is  a  degree  redder  than  natural,  although  there  is  no  sore- 
ness or  uneasiness  experienced  in  swallowing ;  but  the  uvula  is 
almost  invariably  relaxed.  If  this  latter  organ  be  carefully  exa- 
mined in  a  number  of  cases,  it  will  generally  be  found  that  the